Provider Demographics
NPI:1033267323
Name:PROFUNCTION PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:PROFUNCTION PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:908-653-1776
Mailing Address - Street 1:30 S UNION AVE
Mailing Address - Street 2:
Mailing Address - City:CRANFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07016-2833
Mailing Address - Country:US
Mailing Address - Phone:908-653-1776
Mailing Address - Fax:908-653-1779
Practice Address - Street 1:30 S UNION AVE
Practice Address - Street 2:
Practice Address - City:CRANFORD
Practice Address - State:NJ
Practice Address - Zip Code:07016-2833
Practice Address - Country:US
Practice Address - Phone:908-653-1776
Practice Address - Fax:908-653-1779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00814100261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ076224Medicare PIN