Basic Information
| Provider Information | |||||||||
| NPI: | 1063001048 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TESORO-RACELIS | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | NIKO | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1104 HECKEL DR | ||||||||
| Address2: | |||||||||
| City: | MOUNTAINSIDE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070922029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9088689227 | ||||||||
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| Practice Location | |||||||||
| Address1: | 355 GRAND ST | ||||||||
| Address2: | |||||||||
| City: | JERSEY CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 073024321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019152000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2021 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01924500 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.