Basic Information
| Provider Information | |||||||||
| NPI: | 1952346355 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OPTIMUM ORTHOPEDICS PHYSICAL THERAPY & REHAB CENTER II LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | ONE GREENWOOD AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MONTCLAIR | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070423617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737462424 | ||||||||
| FaxNumber: | 9737465030 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 GREENWOOD AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MONTCLAIR | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070423649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737462424 | ||||||||
| FaxNumber: | 9737465030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 09/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | CERULLO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | Q. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/OPERATOR | ||||||||
| AuthorizedOfficialTelephone: | 9737462424 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MSPT, CSCS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | QA10818 | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | QA08619 | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225XH1200X | TR01594 | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 225100000X | QA08051 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.