Healthcare Provider Details

I. General information

NPI: 1760226161
Provider Name (Legal Business Name): PLYMOUTH REHAB GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2024
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 12TH ST APT 203
PALISADES PARK NJ
07650-2371
US

IV. Provider business mailing address

800 12TH ST APT 203
PALISADES PARK NJ
07650-2371
US

V. Phone/Fax

Practice location:
  • Phone: 551-999-3616
  • Fax:
Mailing address:
  • Phone: 551-999-3616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. SAMUEL MIN
Title or Position: DOCTOR OF PHYSICAL THERAPY
Credential: DPT
Phone: 551-999-3616