Basic Information
| Provider Information | |||||||||
| NPI: | 1225018617 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHORE WELLNESS CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 MONMOUTH RD | ||||||||
| Address2: | |||||||||
| City: | OAKHURST | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077551515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7326601560 | ||||||||
| FaxNumber: | 7326601562 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 MONMOUTH RD | ||||||||
| Address2: | |||||||||
| City: | OAKHURST | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077551515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7326601560 | ||||||||
| FaxNumber: | 7326601562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 10/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | SANTAMARIA | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7326601560 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 2251H1200X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand |
No ID Information.