Healthcare Provider Details

I. General information

NPI: 1760764484
Provider Name (Legal Business Name): IPTA CLINICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 ROUTE 70 SUITE 19
MEDFORD NJ
08055-2300
US

IV. Provider business mailing address

175 ROUTE 70 SUITE 19
MEDFORD NJ
08055-2300
US

V. Phone/Fax

Practice location:
  • Phone: 609-714-3378
  • Fax: 856-583-6004
Mailing address:
  • Phone: 609-714-3378
  • Fax: 856-583-6004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEANINE DOHERTY
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 609-257-3750