Healthcare Provider Details

I. General information

NPI: 1780883199
Provider Name (Legal Business Name): JAIME LUIS NIEVES JR. P.T.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 LAUREL AVE
KEANSBURG NJ
07734-1125
US

IV. Provider business mailing address

1123B HOLLYWOOD RD
LINDEN NJ
07036-5629
US

V. Phone/Fax

Practice location:
  • Phone: 732-787-8100
  • Fax:
Mailing address:
  • Phone: 908-531-9224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number40 QB00191000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: