Basic Information
| Provider Information | |||||||||
| NPI: | 1407108434 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACHIEVE SPORTMEDICINE REHAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 668 WYCKOFF AVE | ||||||||
| Address2: | |||||||||
| City: | WYCKOFF | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074811430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018910411 | ||||||||
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| Practice Location | |||||||||
| Address1: | 668 WYCKOFF AVE | ||||||||
| Address2: | |||||||||
| City: | WYCKOFF | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074811430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018910411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2012 | ||||||||
| LastUpdateDate: | 10/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | MCAULEY | ||||||||
| AuthorizedOfficialFirstName: | EILEEN | ||||||||
| AuthorizedOfficialMiddleName: | KRINGLE | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 2018910411 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | 40QA00327500 | NJ | Y | Agencies | Public Health or Welfare |
No ID Information.