Healthcare Provider Details

I. General information

NPI: 1508014242
Provider Name (Legal Business Name): PODIATRIC WELLNESS SPORTS MEDICINE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2008
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MAIN ST SUITE E
NEW EGYPT NJ
08533-1400
US

IV. Provider business mailing address

10 MAIN ST SUITE E
NEW EGYPT NJ
08533-1400
US

V. Phone/Fax

Practice location:
  • Phone: 609-758-8008
  • Fax:
Mailing address:
  • Phone: 609-758-8008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number25MD00263400
License Number StateNJ

VIII. Authorized Official

Name: DR. VINCENT PHILLIP DELLEGROTTI SR.
Title or Position: PRESIDENT/PODIATRIST
Credential: DPM
Phone: 609-758-8008