Provider Demographics
NPI:1831550078
Name:PROVERE PHYSICAL THERAPY - MONTCLAIR, LLC
Entity type:Organization
Organization Name:PROVERE PHYSICAL THERAPY - MONTCLAIR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CEDRIC
Authorized Official - Middle Name:
Authorized Official - Last Name:HADDAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-485-8971
Mailing Address - Street 1:637 WYCKOFF AVE
Mailing Address - Street 2:UNIT 364
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-1438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 ELM ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3451
Practice Address - Country:US
Practice Address - Phone:201-485-8971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty