Basic Information
| Provider Information | |||||||||
| NPI: | 1417351164 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MISTRY | ||||||||
| FirstName: | DAVE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 194 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MILLBURN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070411144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735649559 | ||||||||
| FaxNumber: | 9735649717 | ||||||||
| Practice Location | |||||||||
| Address1: | 194 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MILLBURN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070411144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735649559 | ||||||||
| FaxNumber: | 9735649717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2014 | ||||||||
| LastUpdateDate: | 10/09/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01563500 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.