Basic Information
Provider Information | |||||||||
NPI: | 1265484331 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KIPNIS ORTHOPAEDIC REHAB OF SECAUCUS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KIPNIS REHAB OF SECAUCUS LLC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 150 FLANAGAN WAY | ||||||||
Address2: |   | ||||||||
City: | SECAUCUS | ||||||||
State: | NJ | ||||||||
PostalCode: | 070943433 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2013190010 | ||||||||
FaxNumber: | 2013190349 | ||||||||
Practice Location | |||||||||
Address1: | 150 FLANAGAN WAY | ||||||||
Address2: |   | ||||||||
City: | SECAUCUS | ||||||||
State: | NJ | ||||||||
PostalCode: | 070943433 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2013190010 | ||||||||
FaxNumber: | 2013190349 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2006 | ||||||||
LastUpdateDate: | 02/25/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KIPNIS | ||||||||
AuthorizedOfficialFirstName: | ILENA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 2013190010 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA00411700 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.