=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104358787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONVERGENT MOVEMENT AND PERFORMANCE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2017
-----------------------------------------------------
Last Update Date | 10/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 US HIGHWAY 22 EAST SUITE 2000 UNIT W7
-----------------------------------------------------
City | BRIDGEWATER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08807-2943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-304-3620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 726 ROUTE 202 SUITE 320 UNIT 200
-----------------------------------------------------
City | BRIDGEWATER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08807-2737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PHYSICAL THERAPIST
-----------------------------------------------------
Name | DR. EUGENE KETSELMAN
-----------------------------------------------------
Credential | D.P.T.
-----------------------------------------------------
Telephone | 908-304-3620
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 40QA01566100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------