MEDICARE: FOREVER ACTIVE PHYSICAL THERAPY & SPORTS PERFORMANCE 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	2251G0304X	Geriatric Physical Therapist

General Provider Information

NPI Number	:	1518635598
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOREVER ACTIVE PHYSICAL THERAPY & SPORTS PERFORMANCE LLC

Provider Business Mailing Address
First Line	:	1236 AUDUBON DR
Second Line	:
City	:	TOMS RIVER
State	:	NJ
Zip	:	08753-3903
Country	:	US
Telephone Number	:	732-575-3275
Fax Number	:

Provider Business Practice Location Address
First Line	:	1236 AUDUBON DR
Second Line	:
City	:	TOMS RIVER
State	:	NJ
Zip	:	08753-3903
Country	:	US
Telephone Number	:	732-575-3275
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT, LEAD PHYSICAL THERAPIST
Name	:	BRADLEY PUGLISI
Credential	:	PT, DPT
Telephone Number	:	732-575-3275

Provider Enumeration Date	:	09/02/2021
Last Update Date	:	09/02/2021

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