MEDICARE: PRIME PHYSICAL THERAPY & SPORTS CARE 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	2251X0800X	Orthopedic Physical Therapist

General Provider Information

NPI Number	:	1639642374
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME PHYSICAL THERAPY & SPORTS CARE LLC

Provider Business Mailing Address
First Line	:	160 WHITE RD STE 104
Second Line	:
City	:	LITTLE SILVER
State	:	NJ
Zip	:	07739-1167
Country	:	US
Telephone Number	:	732-383-8295
Fax Number	:

Provider Business Practice Location Address
First Line	:	160 WHITE RD STE 104
Second Line	:
City	:	LITTLE SILVER
State	:	NJ
Zip	:	07739-1167
Country	:	US
Telephone Number	:	732-383-8295
Fax Number	:	732-383-8370

Authorized Official
Title or Position	:	PHYSICAL THERAPIST/OWNER
Name	:	DR. JONATHON CORBACIO
Credential	:	DPT
Telephone Number	:	732-383-8295

Provider Enumeration Date	:	01/04/2019
Last Update Date	:	01/20/2023

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