Healthcare Provider Details

I. General information

NPI: 1457888091
Provider Name (Legal Business Name): LIFE PT PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2017
Last Update Date: 05/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 ROUTE 70 STE A6
LAKEWOOD NJ
08701-5847
US

IV. Provider business mailing address

525 ROUTE 70 STE A6
LAKEWOOD NJ
08701-5847
US

V. Phone/Fax

Practice location:
  • Phone: 732-534-4794
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number40QA01464000
License Number StateNJ

VIII. Authorized Official

Name: CHAYA ENGLARD
Title or Position: OWNER
Credential: DPT
Phone: 732-534-4794