Healthcare Provider Details

I. General information

NPI: 1700011814
Provider Name (Legal Business Name): E.A.S. PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2009
Last Update Date: 10/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 GRAND AVE SOUTH BUILDING #504
PALISADES PARK NJ
07650-1076
US

IV. Provider business mailing address

21 GRAND AVE SOUTH BUILDING #504
PALISADES PARK NJ
07650
US

V. Phone/Fax

Practice location:
  • Phone: 201-941-8990
  • Fax: 201-941-0991
Mailing address:
  • Phone: 201-941-8990
  • Fax: 201-941-0991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA00899500
License Number StateNJ

VIII. Authorized Official

Name: HYEO YOUNG PARK
Title or Position: OWNER
Credential: RPT
Phone: 201-313-4840