Basic Information
| Provider Information | |||||||||
| NPI: | 1992009203 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAST TRACK PHYSICAL THERAPY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | SOMERDALE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080830009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565046930 | ||||||||
| FaxNumber: | 8565046934 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 S WHITE HORSE PIKE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | SOMERDALE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080831253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565046930 | ||||||||
| FaxNumber: | 8565046934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2010 | ||||||||
| LastUpdateDate: | 07/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | LASER | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 8565046930 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 40QA01113200 | NJ | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.