Provider Demographics
NPI:1073204020
Name:IMHOMOH, KELVIN
Entity Type:Individual
Prefix:
First Name:KELVIN
Middle Name:
Last Name:IMHOMOH
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 1:13 GERARD PL
Mailing Address - Street 2:
Mailing Address - City:PARLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08859-2306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 INDUSTRIAL WAY E
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-3318
Practice Address - Country:US
Practice Address - Phone:732-544-1557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00342800225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJI57604306109882OtherDRIVERS LICENSE