Provider Demographics
NPI:1417228917
Name:EAST COAST REHABILITATION SERVICES LLC
Entity Type:Organization
Organization Name:EAST COAST REHABILITATION SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NISPEROS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:973-704-7734
Mailing Address - Street 1:700 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:NJ
Mailing Address - Zip Code:07033-2012
Mailing Address - Country:US
Mailing Address - Phone:908-241-8591
Mailing Address - Fax:855-631-4348
Practice Address - Street 1:700 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:KENILWORTH
Practice Address - State:NJ
Practice Address - Zip Code:07033-2012
Practice Address - Country:US
Practice Address - Phone:908-241-8591
Practice Address - Fax:855-631-4348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-16
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01110500261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy