=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134731755
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOVEMENT 4 WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2020
-----------------------------------------------------
Last Update Date | 08/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 E CHESTNUT AVE UNIT 2
-----------------------------------------------------
City | MERCHANTVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08109-2505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-434-7755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 331 PRESTON AVE APT 206
-----------------------------------------------------
City | VOORHEES
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08043-1722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-669-1896
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / PHYSICAL THERAPIST
-----------------------------------------------------
Name | DR. ERNESTO RAUL MENDEZ
-----------------------------------------------------
Credential | PT, DPT, OCS
-----------------------------------------------------
Telephone | 787-669-1896
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------