=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841052628
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENVILLE MEDICAL HEALTH CENTER & SPORTS REHAB P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2024
-----------------------------------------------------
Last Update Date | 01/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 161 E MAIN ST
-----------------------------------------------------
City | DENVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07834-2647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-627-7888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 161 E MAIN ST
-----------------------------------------------------
City | DENVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07834-2647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-627-7888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | DEMETRIA GLAAB
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-627-7888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------