Provider Demographics
NPI:1407954563
Name:PERSONALIZED PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:PERSONALIZED PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MINEO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-349-4170
Mailing Address - Street 1:325 W WATER STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753
Mailing Address - Country:US
Mailing Address - Phone:732-349-4170
Mailing Address - Fax:732-349-6758
Practice Address - Street 1:325 W WATER STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753
Practice Address - Country:US
Practice Address - Phone:732-349-4170
Practice Address - Fax:732-349-6758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00771300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
083424Medicare ID - Type Unspecified