Healthcare Provider Details

I. General information

NPI: 1447615364
Provider Name (Legal Business Name): VINCENT CAVALIERE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2015
Last Update Date: 12/18/2015
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 Code225100000X
TaxonomyPhysical Therapist
License Number40QA01621800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: