=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518679190
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGNA VITA REHAB AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2022
-----------------------------------------------------
Last Update Date | 01/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 61 DAVIS AVE
-----------------------------------------------------
City | BLOOMFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07003-4116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-566-4772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 61 DAVIS AVE
-----------------------------------------------------
City | BLOOMFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07003-4116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-566-4772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING DIRECTOR
-----------------------------------------------------
Name | ROSLYN MANDRIQUE BATIANCILA
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 973-566-4772
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------