Basic Information
| Provider Information | |||||||||
| NPI: | 1528489572 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JAG PHYSICAL THERAPY NY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 622 EAGLE ROCK AVE | ||||||||
| Address2: | |||||||||
| City: | WEST ORANGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9736690078 | ||||||||
| FaxNumber: | 9736691113 | ||||||||
| Practice Location | |||||||||
| Address1: | 274 MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100160701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9736690078 | ||||||||
| FaxNumber: | 9736691113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2013 | ||||||||
| LastUpdateDate: | 12/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | GALLUCCI | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9736690078 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | DPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.