=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093855322
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARDEN STATE PHYSICAL THERAPY AND WELLNESS CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 06/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 N BROAD ST STE 102
-----------------------------------------------------
City | ELIZABETH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07208-2310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-354-1511
-----------------------------------------------------
Fax | 908-659-9229
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 N BROAD ST STE 102
-----------------------------------------------------
City | ELIZABETH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07208-2310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-354-1511
-----------------------------------------------------
Fax | 908-659-9229
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. OLFEA DIGAMON MANGLE
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 908-354-1511
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 40QA00504100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------