=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316279292
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN REHABILITATION TECHNOLOGIES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2010
-----------------------------------------------------
Last Update Date | 08/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 431 E MAIN STREET (ROUTE 53) SUITE 2
-----------------------------------------------------
City | DENVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-784-4286
-----------------------------------------------------
Fax | 973-784-4287
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 329 MIDDLE COUNTRY ROAD SUITE 2
-----------------------------------------------------
City | SMITHTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11787-2821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-360-6400
-----------------------------------------------------
Fax | 631-360-6449
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WILLIAM M SCHWING
-----------------------------------------------------
Credential | LPO, CPO
-----------------------------------------------------
Telephone | 973-784-4286
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | 45PO00011500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------