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General NPI Number Information
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NPI Number | 1487743506
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Entity Type | Organization
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Legal Business Name | BEACON PHYSICAL THERAPY PC
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Dates
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Enumeration Date | 10/12/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 34 YALE STREET
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City | MAPLEWOOD
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State | NJ
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Zip | 07040
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Country | US
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Telephone | 973-762-1988
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Fax |
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Provider Business Mailing Address
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Address Line | 45 CHURCH STREET APT C 17
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City | MONTCLAIR
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State | NJ
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Zip | 07042
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Country | US
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Telephone | 973-233-1514
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. GREGORY SCOTT DAVIS
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Credential | PHYSICAL THERAPIST
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Telephone | 973-233-1514
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 40QA00979300
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License Number State | NJ
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