=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740577964
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEVIN NORMAN KOPACK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2011
-----------------------------------------------------
Last Update Date | 06/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 297 PASSAIC AVE UNIT 3
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07004-2503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-227-4280
-----------------------------------------------------
Fax | 973-227-4210
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 297 PASSAIC AVE STE 3
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07004-2548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-227-4280
-----------------------------------------------------
Fax | 973-227-4210
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST/OWNER
-----------------------------------------------------
Name | MR. KEVIN NORMAN KOPACK
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 973-227-4280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 40QAO0335300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------