Basic Information
| Provider Information | |||||||||
| NPI: | 1962648170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIRABUENO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | PT,DPT | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1002 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FORDS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088631514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7324076308 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1175 ROOSEVELT AVE | ||||||||
| Address2: | |||||||||
| City: | CARTERET | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070081536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7325412233 | ||||||||
| FaxNumber: | 7325412237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2008 | ||||||||
| LastUpdateDate: | 03/15/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 40QA01300700 | NJ | Y | Other Service Providers | Specialist |
No ID Information.