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General NPI Number Information
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NPI Number | 1972936417
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Entity Type | Organization
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Legal Business Name | INDIGO AQUATIC THERAPY LLC
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Dates
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Enumeration Date | 08/20/2013
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Last Update Date | 01/24/2014
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Provider Practice Location Address
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Address Line | 599 GOFFLE HILL RD
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City | HAWTHORNE
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State | NJ
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Zip | 07506-3037
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Country | US
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Telephone | 973-949-3927
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Fax |
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Provider Business Mailing Address
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Address Line | 599 GOFFLE HILL RD
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City | HAWTHORNE
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State | NJ
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Zip | 07506-3037
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Country | US
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Telephone | 973-949-3927
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | STACEY O'CONNOR
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Credential | DPT
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Telephone | 973-949-3927
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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 | 40QA01348800
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License Number State | NJ
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