Provider Demographics
NPI:1306367248
Name:PATAGONIA FITNESS LLC
Entity Type:Organization
Organization Name:PATAGONIA FITNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:
Authorized Official - Last Name:CHIABO
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, COMT
Authorized Official - Phone:551-486-6157
Mailing Address - Street 1:201 MARIN BLVD APT 307
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-6492
Mailing Address - Country:US
Mailing Address - Phone:551-486-6157
Mailing Address - Fax:
Practice Address - Street 1:201 MARIN BLVD APT 307
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-6492
Practice Address - Country:US
Practice Address - Phone:551-486-6157
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029622225100000X
NJ40QA01345700225100000X
NJ0400319126225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty