Basic Information
| Provider Information | |||||||||
| NPI: | 1912958083 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACHIEVE SPORTS MEDICINE & REHAB, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 491 EISENHOWER COURT | ||||||||
| Address2: | |||||||||
| City: | WYCKOFF | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018470881 | ||||||||
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| Practice Location | |||||||||
| Address1: | 168 FRANKLIN TURNPIKE | ||||||||
| Address2: | SUITE 103B | ||||||||
| City: | WALDWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014937440 | ||||||||
| FaxNumber: | 2014937445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 12/10/2013 | ||||||||
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| AuthorizedOfficialLastName: | DIFELICE | ||||||||
| AuthorizedOfficialFirstName: | CARLA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2014937440 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.