Provider Demographics
NPI:1003932880
Name:PRESTIGE PHYSICAL THERAPY, L.L.C.
Entity Type:Organization
Organization Name:PRESTIGE PHYSICAL THERAPY, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:201-921-7766
Mailing Address - Street 1:199 MANITO AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07436-4013
Mailing Address - Country:US
Mailing Address - Phone:201-921-7766
Mailing Address - Fax:
Practice Address - Street 1:463 LIVINGSTON ST
Practice Address - Street 2:SUITE 203
Practice Address - City:NORWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07648-1344
Practice Address - Country:US
Practice Address - Phone:201-921-7766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00966100261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy