Provider Demographics
NPI:1093935595
Name:MATTAPPALLIL, REGGIE C (PTA)
Entity Type:Individual
Prefix:MR
First Name:REGGIE
Middle Name:C
Last Name:MATTAPPALLIL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:MR
Other - First Name:RAJIMONE
Other - Middle Name:C
Other - Last Name:MATTAPPALLIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:36 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:EAST HANOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07936-3027
Mailing Address - Country:US
Mailing Address - Phone:973-884-4565
Mailing Address - Fax:
Practice Address - Street 1:459 PASSAIC AVE
Practice Address - Street 2:
Practice Address - City:WEST CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-7457
Practice Address - Country:US
Practice Address - Phone:973-276-7887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility