Basic Information
| Provider Information | |||||||||
| NPI: | 1962425314 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRO PHYSICAL THERAPY, LLC | ||||||||
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| OtherOrganizationName: | PRO SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 EMERY AVE | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | RANDOLPH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078691368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738959925 | ||||||||
| FaxNumber: | 9738959927 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 EMERY AVE | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | RANDOLPH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078691368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738959925 | ||||||||
| FaxNumber: | 9738959927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 10/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | DEVINCENTIS | ||||||||
| AuthorizedOfficialFirstName: | JODI | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9738959925 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.