Healthcare Provider Details

I. General information

NPI: 1649561812
Provider Name (Legal Business Name): ADVANCED PHYSICAL MEDICINE AND REHABILITATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2011
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1719 MAIN ST SUITE 101
LAKE COMO NJ
07719-3097
US

IV. Provider business mailing address

1719 MAIN ST SUITE 101
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 Number40QA01350900
License Number StateNJ

VIII. Authorized Official

Name: DR. DANIEL REIZIS
Title or Position: MANAGING MEMBER/PHYSICAL THERAPIST
Credential: PT
Phone: 732-894-9200