MEDICARE: BARNEGAT SPORTS REHABILITATION & 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	40QA01038900	NJ

General Provider Information

NPI Number	:	1477617405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BARNEGAT SPORTS REHABILITATION & PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	890 W BAY AVE
Second Line	:	SUITE A
City	:	BARNEGAT
State	:	NJ
Zip	:	08005-2150
Country	:	US
Telephone Number	:	609-698-1073
Fax Number	:	609-698-1473

Provider Business Practice Location Address
First Line	:	890 W BAY AVE
Second Line	:	SUITE A
City	:	BARNEGAT
State	:	NJ
Zip	:	08005-2150
Country	:	US
Telephone Number	:	609-698-1073
Fax Number	:	609-698-1473

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ERNEST J GAMBLE
Credential	:	PT
Telephone Number	:	609-698-1073

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	01/15/2008

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