Provider Demographics
NPI:1558737395
Name:EDGE PHYSICAL THERAPY AND SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:EDGE PHYSICAL THERAPY AND SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, OCS
Authorized Official - Phone:201-482-9523
Mailing Address - Street 1:16 ARCADIAN WAY
Mailing Address - Street 2:SUITE C6
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-1291
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16 ARCADIAN WAY
Practice Address - Street 2:SUITE C6
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-1291
Practice Address - Country:US
Practice Address - Phone:201-483-9523
Practice Address - Fax:201-483-9534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-17
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01510100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty