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General NPI Number Information
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NPI Number | 1871216614
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Entity Type | Individual
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Provider Name | PREMALATHA MANICKAM SR.
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Gender | Female
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Dates
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Enumeration Date | 09/26/2022
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Last Update Date | 10/10/2023
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Provider Practice Location Address
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Address Line | 270 US HIGHWAY 206 S SPC A114
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City | CHESTER
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State | NJ
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Zip | 07930-2491
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Country | US
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Telephone | 908-888-0441
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Fax |
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Provider Business Mailing Address
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Address Line | 270 US HIGHWAY 206 S SPC A114
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City | CHESTER
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State | NJ
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Zip | 07930-2491
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Country | US
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Telephone | 908-888-0441
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Fax | 732-289-3965
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 40QA02086700
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License Number State | NJ
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