=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427851567
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOULEVARD PHYSICAL THERAPY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2025
-----------------------------------------------------
Last Update Date | 03/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 467 BOULEVARD
-----------------------------------------------------
City | KENILWORTH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07033-1664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-377-4095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1203 EMERSON AVE
-----------------------------------------------------
City | NORTH CAPE MAY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08204-2106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-377-4095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ADAM S GREEN
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 908-377-4095
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------