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General NPI Number Information
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NPI Number | 1700251089
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Entity Type | Organization
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Legal Business Name | PROVERE PHYSICAL THERAPY - SPARTA
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Dates
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Enumeration Date | 12/11/2015
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Last Update Date | 12/11/2015
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Provider Practice Location Address
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Address Line | 14 PARK LAKE RD
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City | SPARTA
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State | NJ
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Zip | 07871-3241
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Country | US
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Telephone | 201-485-8971
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Fax |
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Provider Business Mailing Address
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Address Line | 637 WYCKOFF AVE PMB 362
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City | WYCKOFF
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State | NJ
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Zip | 07481-1438
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. CEDRIC HADDAD
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Credential | D.P.T
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Telephone | 732-221-7617
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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 | 40QA00611400
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License Number State | NJ
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