Provider Demographics
NPI:1578501524
Name:ADVANCED PHYSICAL MEDICINE & REHABILATION CENTER LLC
Entity Type:Organization
Organization Name:ADVANCED PHYSICAL MEDICINE & REHABILATION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DENINO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:732-202-1200
Mailing Address - Street 1:1645 STATE HIGHWAY 88
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-3049
Mailing Address - Country:US
Mailing Address - Phone:732-202-1200
Mailing Address - Fax:732-202-1300
Practice Address - Street 1:1645 STATE HIGHWAY 88
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3049
Practice Address - Country:US
Practice Address - Phone:732-202-1200
Practice Address - Fax:732-202-1300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC003514111N00000X
NJ4OQAO1152600174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ049523Medicare ID - Type UnspecifiedGROUP NUMBER
NJ6055380001Medicare NSC