=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376809715
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SALANDRA PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2012
-----------------------------------------------------
Last Update Date | 04/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 THOMPSON CLOSE
-----------------------------------------------------
City | HILLSBOROUGH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08844-5224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-285-2243
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 THOMPSON CLOSE
-----------------------------------------------------
City | HILLSBOROUGH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08844-5224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-285-2243
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. DIANE REGINA SALANDRA
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 908-874-5843
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 40QA00390000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------