=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730734070
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIP REHABILITATION INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2019
-----------------------------------------------------
Last Update Date | 08/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 727 JORALEMON ST
-----------------------------------------------------
City | BELLEVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07109-1455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-751-2060
-----------------------------------------------------
Fax | 973-751-2291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 599
-----------------------------------------------------
City | ROSELAND
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07068-0599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-751-2060
-----------------------------------------------------
Fax | 973-751-2291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | ANTONIO CICCONE
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 973-751-2060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------