Healthcare Provider Details

I. General information

NPI: 1386790467
Provider Name (Legal Business Name): INNOCENT URAYAI RWAKONDA PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218A SHORE DRIVE
MONTAGUE NJ
07827-0263
US

IV. Provider business mailing address

PO BOX 1263
MONTAGUE NJ
07827-0263
US

V. Phone/Fax

Practice location:
  • Phone: 973-293-8351
  • Fax: 973-293-8351
Mailing address:
  • Phone: 973-293-8351
  • Fax: 973-293-8351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT010414L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: