Provider Demographics
NPI:1083097745
Name:SHORE KIDS PEDIATRIC THERAPIES, LLC
Entity Type:Organization
Organization Name:SHORE KIDS PEDIATRIC THERAPIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST/CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:JILL
Authorized Official - Last Name:GARGUILO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-460-1500
Mailing Address - Street 1:14 BRIDGEWATERS DR
Mailing Address - Street 2:
Mailing Address - City:OCEANPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07757-1162
Mailing Address - Country:US
Mailing Address - Phone:732-460-1500
Mailing Address - Fax:732-460-1501
Practice Address - Street 1:14 BRIDGEWATERS DR
Practice Address - Street 2:
Practice Address - City:OCEANPORT
Practice Address - State:NJ
Practice Address - Zip Code:07757
Practice Address - Country:US
Practice Address - Phone:732-460-1500
Practice Address - Fax:732-460-1501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00397400174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty