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General NPI Number Information
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NPI Number | 1770072142
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Entity Type | Organization
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Legal Business Name | NATTY BANDASAK PHYSIO PERFORMANCE
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Dates
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Enumeration Date | 05/01/2018
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Last Update Date | 12/24/2024
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Provider Practice Location Address
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Address Line | 55 EAGLE ROCK AVE
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City | EAST HANOVER
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State | NJ
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Zip | 07936-3143
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Country | US
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Telephone | 973-397-5868
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Fax |
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Provider Business Mailing Address
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Address Line | 220 W JERSEY ST APT 5F
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City | ELIZABETH
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State | NJ
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Zip | 07202-1319
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Country | US
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Telephone | 973-379-0198
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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. NATTY BANDASAK
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Credential | DPT
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Telephone | 973-370-0198
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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 |
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License Number State |
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