Healthcare Provider Details

I. General information

NPI: 1962925412
Provider Name (Legal Business Name): PROVERE PHYSICAL THERAPY - PARAMUS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2017
Last Update Date: 07/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 SETTE DR BLDG E
PARAMUS NJ
07652-2940
US

IV. Provider business mailing address

637 WYCKOFF AVE PMB 361
WYCKOFF NJ
07481-1438
US

V. Phone/Fax

Practice location:
  • Phone: 201-538-7131
  • Fax: 201-538-7131
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierNONE
Identifier TypeOTHER
Identifier State
Identifier IssuerNONE

VIII. Authorized Official

Name: CEDRIC HADDAD
Title or Position: CO-OWNER
Credential:
Phone: 201-538-7131