Healthcare Provider Details

I. General information

NPI: 1114336138
Provider Name (Legal Business Name): ADVANCED PHYSICAL MEDICINE & REHABILITATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2014
Last Update Date: 08/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1719 MAIN ST
LAKE COMO NJ
07719-3097
US

IV. Provider business mailing address

1719 MAIN ST
LAKE COMO NJ
07719-3097
US

V. Phone/Fax

Practice location:
  • Phone: 732-894-9200
  • Fax: 732-894-9202
Mailing address:
  • Phone: 732-894-9200
  • Fax: 732-894-9202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number25MZ00090400
License Number StateNJ

VIII. Authorized Official

Name: DR. DANIEL REIZIS
Title or Position: MANAGING MEMBER
Credential: PT, DPT
Phone: 732-894-9200