Healthcare Provider Details

I. General information

NPI: 1992237598
Provider Name (Legal Business Name): TIDEWATCH PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2017
Last Update Date: 06/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 AVENUE AT THE CMN STE 200A
SHREWSBURY NJ
07702-4587
US

IV. Provider business mailing address

39 AVENUE AT THE CMN STE 200A
SHREWSBURY NJ
07702-4587
US

V. Phone/Fax

Practice location:
  • Phone: 732-204-7741
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01328500
License Number StateNJ

VIII. Authorized Official

Name: JOHN BLUMBERGER
Title or Position: MANAGING MEMBER
Credential: PT, DPT, MBA
Phone: 732-204-7741