Provider Demographics
NPI:1477622496
Name:WANTAGE PHYSICAL REHABILITATION LLC
Entity Type:Organization
Organization Name:WANTAGE PHYSICAL REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PREMSHANKAR
Authorized Official - Middle Name:
Authorized Official - Last Name:NADAR
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:201-912-7491
Mailing Address - Street 1:359 ROUTE 23
Mailing Address - Street 2:
Mailing Address - City:SUSSEX
Mailing Address - State:NJ
Mailing Address - Zip Code:07461-3105
Mailing Address - Country:US
Mailing Address - Phone:973-875-1974
Mailing Address - Fax:973-875-1984
Practice Address - Street 1:359 ROUTE 23
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:NJ
Practice Address - Zip Code:07461-3105
Practice Address - Country:US
Practice Address - Phone:973-875-1974
Practice Address - Fax:973-875-1984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1231776225100000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ094197Medicare ID - Type Unspecified