MEDICARE: MINNELLA PHYSICAL THERAPY, 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	261QP2000X	Physical Therapy Clinic/Center	40QA01021500	NJ

General Provider Information

NPI Number	:	1346480712
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINNELLA PHYSICAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	217 BUCHANAN AVE
Second Line	:
City	:	EDGEWATER PARK
State	:	NJ
Zip	:	08010-2109
Country	:	US
Telephone Number	:	973-919-4862
Fax Number	:	866-699-1796

Provider Business Practice Location Address
First Line	:	217 BUCHANAN AVE
Second Line	:
City	:	EDGEWATER PARK
State	:	NJ
Zip	:	08010-2109
Country	:	US
Telephone Number	:	973-919-4862
Fax Number	:	866-699-1796

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	DR. LEWIS M MINNELLA
Credential	:	PT, DPT
Telephone Number	:	973-919-4862

Provider Enumeration Date	:	02/25/2009
Last Update Date	:	02/25/2009

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