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General NPI Number Information
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NPI Number | 1083097745
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Entity Type | Organization
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Legal Business Name | SHORE KIDS PEDIATRIC THERAPIES, LLC
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Dates
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Enumeration Date | 06/30/2015
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Last Update Date | 06/30/2015
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Provider Practice Location Address
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Address Line | 14 BRIDGEWATERS DR
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City | OCEANPORT
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State | NJ
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Zip | 07757
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Country | US
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Telephone | 732-460-1500
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Fax | 732-460-1501
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Provider Business Mailing Address
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Address Line | 14 BRIDGEWATERS DR
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City | OCEANPORT
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State | NJ
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Zip | 07757-1162
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Country | US
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Telephone | 732-460-1500
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Fax | 732-460-1501
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPIST/CO-OWNER
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Name | TRACY JILL GARGUILO
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Credential |
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Telephone | 732-460-1500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 46TR00397400
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License Number State | NJ
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