MEDICARE: PREMIUM CARE 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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1477941979
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIUM CARE PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	9 ALMARK TER
Second Line	:
City	:	OCEAN
State	:	NJ
Zip	:	07712-3217
Country	:	US
Telephone Number	:	201-942-4555
Fax Number	:	973-475-9165

Provider Business Practice Location Address
First Line	:	2520 JOHN F KENNEDY BLVD
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07304-2054
Country	:	US
Telephone Number	:	201-942-4555
Fax Number	:	973-475-9165

Authorized Official
Title or Position	:	OWNER
Name	:	MR. SCOTT MAKOWER
Credential	:	PT
Telephone Number	:	201-942-4555

Provider Enumeration Date	:	01/06/2015
Last Update Date	:	04/09/2015

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