Provider Demographics
NPI:1003696147
Name:VILLANUEVA, JOMARI
Entity Type:Individual
Prefix:
First Name:JOMARI
Middle Name:
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 ASHBURN AVE
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-2363
Mailing Address - Country:US
Mailing Address - Phone:848-448-5777
Mailing Address - Fax:
Practice Address - Street 1:35 ASHBURN AVE
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2363
Practice Address - Country:US
Practice Address - Phone:848-448-5777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01217400261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy