=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093386252
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DYLAN JAMES CORONA LMT, CPT, CES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2021
-----------------------------------------------------
Last Update Date | 07/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 214 PARK AVE
-----------------------------------------------------
City | MANALAPAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07726-8372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 848-459-3342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 229 LONG BRANCH AVE
-----------------------------------------------------
City | LONG BRANCH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07740-7564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 848-459-3342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 18KT01235700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------