Healthcare Provider Details

I. General information

NPI: 1710938444
Provider Name (Legal Business Name): WYATT MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 12/05/2020
Certification Date: 12/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 ALDRICH RD UNIT 1E
HOWELL NJ
07731-1978
US

IV. Provider business mailing address

504 ALDRICH RD UNIT 1E
HOWELL NJ
07731-1978
US

V. Phone/Fax

Practice location:
  • Phone: 732-222-8556
  • Fax: 732-222-8663
Mailing address:
  • Phone: 732-222-8556
  • Fax: 732-222-8663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNJ

VIII. Authorized Official

Name: MS. TRACEY J PODOLSKY
Title or Position: EXECUTIVE DIRECTOR
Credential: MPT, CLT-LANA
Phone: 732-222-8556