=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770883225
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLASSIC REHABILITATION, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2010
-----------------------------------------------------
Last Update Date | 11/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 RIVER AVE STE 203
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08701-4738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-367-1888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 RIVER AVE STE 203
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08701-4738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-367-1888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MARC LUBET
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 732-367-1888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------