Provider Demographics
NPI:1093996175
Name:ORTHOPEDIC & SPINE REHABILITATION, LLC
Entity Type:Organization
Organization Name:ORTHOPEDIC & SPINE REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT, OCS
Authorized Official - Phone:856-797-6778
Mailing Address - Street 1:73 N MAPLE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-1782
Mailing Address - Country:US
Mailing Address - Phone:856-797-6778
Mailing Address - Fax:856-797-8011
Practice Address - Street 1:73 N MAPLE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1782
Practice Address - Country:US
Practice Address - Phone:856-797-6778
Practice Address - Fax:856-797-8011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-17
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00312500261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy