Provider Demographics
NPI:1770072142
Name:NATTY BANDASAK PHYSIO PERFORMANCE
Entity type:Organization
Organization Name:NATTY BANDASAK PHYSIO PERFORMANCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BANDASAK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:973-370-0198
Mailing Address - Street 1:220 W JERSEY ST APT 5F
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-1319
Mailing Address - Country:US
Mailing Address - Phone:973-379-0198
Mailing Address - Fax:
Practice Address - Street 1:55 EAGLE ROCK AVE
Practice Address - Street 2:
Practice Address - City:EAST HANOVER
Practice Address - State:NJ
Practice Address - Zip Code:07936-3143
Practice Address - Country:US
Practice Address - Phone:973-397-5868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-01
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty