Healthcare Provider Details

I. General information

NPI: 1548042377
Provider Name (Legal Business Name): JUSTIN REILLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2023
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 KINGS WAY E STE B4
SEWELL NJ
08080-2237
US

IV. Provider business mailing address

100 KINGS WAY E STE B4
SEWELL NJ
08080-2237
US

V. Phone/Fax

Practice location:
  • Phone: 856-256-0007
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA02096000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: