Provider Demographics
NPI:1568677516
Name:GARDEN STATE PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:GARDEN STATE PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DIRECTOR OF REHAB SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDUQUE
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:201-998-6300
Mailing Address - Street 1:44 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH ARLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07031-6350
Mailing Address - Country:US
Mailing Address - Phone:201-998-6300
Mailing Address - Fax:201-998-6344
Practice Address - Street 1:44 RIDGE RD
Practice Address - Street 2:
Practice Address - City:NORTH ARLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07031-6350
Practice Address - Country:US
Practice Address - Phone:201-998-6300
Practice Address - Fax:201-998-6344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-13
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPT40QA00804200261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ067683Medicare PIN