MEDICARE: MATTHEW GEORGE BUSACCA

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	171400000X	Health & Wellness Coach		NJ
2	224Y00000X	Clinical Exercise Physiologist		NJ

General Provider Information

NPI Number	:	1700464377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW GEORGE BUSACCA

Provider Business Mailing Address
First Line	:	1225 GARDENS AVE
Second Line	:
City	:	POINT PLEASANT BORO
State	:	NJ
Zip	:	08742-4043
Country	:	US
Telephone Number	:	732-552-6253
Fax Number	:

Provider Business Practice Location Address
First Line	:	1225 GARDENS AVE
Second Line	:
City	:	POINT PLEASANT BORO
State	:	NJ
Zip	:	08742-4043
Country	:	US
Telephone Number	:	732-552-6253
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2021
Last Update Date	:	04/01/2021

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