=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114081478
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICAL THERAPY CENTER OF PERTH AMBOY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 MARKET ST STE.#101
-----------------------------------------------------
City | PERTH AMBOY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08861-4331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-697-0001
-----------------------------------------------------
Fax | 732-697-0044
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 220 MARKET ST STE.#101
-----------------------------------------------------
City | PERTH AMBOY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08861-4331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-697-0001
-----------------------------------------------------
Fax | 732-697-0044
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMIMISTRATOR
-----------------------------------------------------
Name | MRS. KERI FESSLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 732-697-0001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320700000X
-----------------------------------------------------
Taxonomy Name | Physical Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------