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General NPI Number Information
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NPI Number | 1588855308
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Entity Type | Individual
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Provider Name | ELIZABETH BULOSAN DIVINAGRACIA PHYSICAL THERAPIST
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Gender | Female
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Dates
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Enumeration Date | 08/06/2007
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Last Update Date | 06/30/2016
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Provider Practice Location Address
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Address Line | 9 POST RD STE M12
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City | OAKLAND
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State | NJ
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Zip | 07436-1615
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Country | US
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Telephone | 201-651-0062
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Fax | 201-651-7723
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Provider Business Mailing Address
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Address Line | 3 ROSE COURT 2ND FOR
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City | BAYONNE
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State | NJ
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Zip | 07002
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Country | US
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Telephone | 201-993-9344
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Fax | 201-433-4772
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | 40QA00953000
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License Number State | NJ
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