Healthcare Provider Details

I. General information

NPI: 1821544693
Provider Name (Legal Business Name): PROVERE PHYSICAL THERAPY - SPRINGFIELD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MOUNTAIN AVE
SPRINGFIELD NJ
07081-3414
US

IV. Provider business mailing address

637 WYCKOFF AVE PMB 395
WYCKOFF NJ
07481
US

V. Phone/Fax

Practice location:
  • Phone: 732-221-7617
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: CEDRIC HADDAD
Title or Position: CEO
Credential:
Phone: 732-221-7617