Provider Demographics
NPI:1497894968
Name:PROFESSIONAL SPORTS & ORTHOPAEDIC REHABILITATION ASSOCIATES, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL SPORTS & ORTHOPAEDIC REHABILITATION ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DIRETOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:E
Authorized Official - Last Name:WOLPOV
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:732-617-8090
Mailing Address - Street 1:455 US HIGHWAY 9
Mailing Address - Street 2:CO GAME SHAPE
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-8274
Mailing Address - Country:US
Mailing Address - Phone:732-617-8090
Mailing Address - Fax:732-972-5458
Practice Address - Street 1:455 US HIGHWAY 9
Practice Address - Street 2:CO GAME SHAPE
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-8274
Practice Address - Country:US
Practice Address - Phone:732-617-8090
Practice Address - Fax:732-972-5458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2854674OtherAETNA ID NUMBER
NJ3K4277OtherHEALTHNET
NJ0218901OtherORTHONET-AETNA
NJ0109001OtherORTHONET-HEALTHNET
NJP2650341OtherOXFORD
NJ100381Medicare ID - Type UnspecifiedPHYSICAL THERAPY