Healthcare Provider Details

I. General information

NPI: 1528429545
Provider Name (Legal Business Name): PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF NJ, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2016
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GREENWOOD AVE
MONTCLAIR NJ
07042-3649
US

IV. Provider business mailing address

576 BROADHOLLOW RD
MELVILLE NY
11747-5002
US

V. Phone/Fax

Practice location:
  • Phone: 973-841-5519
  • Fax: 973-746-5030
Mailing address:
  • Phone: 631-359-5859
  • Fax: 631-396-0865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN BRUSH
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 718-819-6805