MEDICARE: MONMOUTH ADVANCED MEDICINE 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	40QA00271700	NJ
2	111NN1001X	Nutrition Chiropractor	38MC00395200	NJ

General Provider Information

NPI Number	:	1922150358
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MONMOUTH ADVANCED MEDICINE LLC

Provider Business Mailing Address
First Line	:	503 STILLWELLS CORNER RD
Second Line	:
City	:	FREEHOLD
State	:	NJ
Zip	:	07728
Country	:	US
Telephone Number	:	732-308-0099
Fax Number	:	732-308-0347

Provider Business Practice Location Address
First Line	:	503 STILLWELLS CORNER RD
Second Line	:
City	:	FREEHOLD
State	:	NJ
Zip	:	07728
Country	:	US
Telephone Number	:	732-308-0099
Fax Number	:	732-308-0347

Authorized Official
Title or Position	:	OWNER
Name	:	STEVEN MARC ZODKOY
Credential	:	D.C.
Telephone Number	:	732-308-0099

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	09/24/2007

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