Provider Demographics
NPI:1568125821
Name:TIDAL PHYSICAL THERAPY & PERFORMANCE
Entity Type:Organization
Organization Name:TIDAL PHYSICAL THERAPY & PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:FREIJOMIL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:856-905-0057
Mailing Address - Street 1:154 COOPER RD STE 1601
Mailing Address - Street 2:
Mailing Address - City:WEST BERLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08091-9146
Mailing Address - Country:US
Mailing Address - Phone:856-905-0057
Mailing Address - Fax:
Practice Address - Street 1:154 COOPER RD STE 1601
Practice Address - Street 2:
Practice Address - City:WEST BERLIN
Practice Address - State:NJ
Practice Address - Zip Code:08091-9146
Practice Address - Country:US
Practice Address - Phone:856-905-0057
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA01932000OtherLICENSE #