MEDICARE: MR. PERSIVAL FAUSTINO BORLONGAN PT

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	225100000X	Physical Therapist	PT QA0006833	NJ

General Provider Information

NPI Number	:	1255303285
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PERSIVAL FAUSTINO BORLONGAN PT

Provider Business Mailing Address
First Line	:	10 PHOENIX CT
Second Line	:
City	:	JACKSON
State	:	NJ
Zip	:	08527-1384
Country	:	US
Telephone Number	:	732-367-3287
Fax Number	:

Provider Business Practice Location Address
First Line	:	5250 MARYLAND AVE
Second Line	:	SRC (REAR OF WALSON)
City	:	FORT DIX
State	:	NJ
Zip	:	08640-5058
Country	:	US
Telephone Number	:	609-562-6487
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	07/08/2007

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