Healthcare Provider Details

I. General information

NPI: 1295837722
Provider Name (Legal Business Name): GLOUCESTER PHYSICAL THERAPY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 MANTUA AVE
PAULSBORO NJ
08066-1178
US

IV. Provider business mailing address

PO BOX 277
PAULSBORO NJ
08066-0277
US

V. Phone/Fax

Practice location:
  • Phone: 856-224-0400
  • Fax: 856-224-0466
Mailing address:
  • Phone: 856-224-0400
  • Fax: 856-224-0466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA00685900
License Number StateNJ

VIII. Authorized Official

Name: DR. MAIKUTLO B KEBAETSE
Title or Position: PRESIDENT
Credential: PHD, PT
Phone: 856-224-0400