MEDICARE: FOOTPRINTS EASTERN PA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1093232530
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOTPRINTS EASTERN PA LLC

Provider Business Mailing Address
First Line	:	PO BOX 1030
Second Line	:
City	:	BRICK
State	:	NJ
Zip	:	08723-0090
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	992 OLD EAGLE SCHOOL RD STE 904
Second Line	:
City	:	WAYNE
State	:	PA
Zip	:	19087-1803
Country	:	US
Telephone Number	:	877-293-7150
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	YESHAYA MARKOVITS
Credential	:
Telephone Number	:	732-903-1964

Provider Enumeration Date	:	08/25/2017
Last Update Date	:	08/25/2017

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