Provider Demographics
NPI:1033353438
Name:BAYONNE PEDIATRIC THERAPY CENTER LLC
Entity Type:Organization
Organization Name:BAYONNE PEDIATRIC THERAPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MAMMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DVM
Authorized Official - Phone:201-436-0014
Mailing Address - Street 1:252 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-2522
Mailing Address - Country:US
Mailing Address - Phone:201-436-0014
Mailing Address - Fax:201-436-0019
Practice Address - Street 1:252 BROADWAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-2522
Practice Address - Country:US
Practice Address - Phone:201-436-0014
Practice Address - Fax:201-436-0019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-29
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00070400305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service