Provider Demographics
NPI:1093855322
Name:GARDEN STATE PHYSICAL THERAPY AND WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:GARDEN STATE PHYSICAL THERAPY AND WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:OLFEA
Authorized Official - Middle Name:DIGAMON
Authorized Official - Last Name:MANGLE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:908-354-1511
Mailing Address - Street 1:700 N BROAD ST STE 102
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-2310
Mailing Address - Country:US
Mailing Address - Phone:908-354-1511
Mailing Address - Fax:908-659-9229
Practice Address - Street 1:700 N BROAD ST STE 102
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-2310
Practice Address - Country:US
Practice Address - Phone:908-354-1511
Practice Address - Fax:908-659-9229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00504100261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ001590204OtherAMERIHEALTH
NJ3K4126OtherHEALTHNET
NJP3440262OtherOXFORD
NJQ23Q61OtherCIGNA
NJQ23Q61OtherEMPIRE BLUE CROSS/BS
NJ0000-225-0032-04OtherUNITED HEALTHCARE
NJ687933OtherACN GROUP
NJ44902OtherORTHONET
NJQ23Q61OtherEMPIRE BLUE CROSS/BS
NJ44902OtherORTHONET
NJ078131Medicare ID - Type UnspecifiedGROUP NUMBER