Healthcare Provider Details

I. General information

NPI: 1629297460
Provider Name (Legal Business Name): ESSEX COUNTY PT REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 MAIN ST
WEST ORANGE NJ
07052-5460
US

IV. Provider business mailing address

80 MAIN ST
WEST ORANGE NJ
07052-5460
US

V. Phone/Fax

Practice location:
  • Phone: 973-736-8686
  • Fax: 973-736-9901
Mailing address:
  • Phone: 973-736-8686
  • Fax: 973-736-9901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberNJMC1943
License Number StateNJ

VIII. Authorized Official

Name: DR. MICHAEL P GOLD
Title or Position: OWNER
Credential: DC
Phone: 973-736-8686