Provider Demographics
NPI:1598386096
Name:TREVOR FENNELL PHYSICAL THERAPY CORP
Entity Type:Organization
Organization Name:TREVOR FENNELL PHYSICAL THERAPY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:
Authorized Official - Last Name:FENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-222-9394
Mailing Address - Street 1:18 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HO HO KUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07423-1530
Mailing Address - Country:US
Mailing Address - Phone:845-222-9394
Mailing Address - Fax:
Practice Address - Street 1:18 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:HO HO KUS
Practice Address - State:NJ
Practice Address - Zip Code:07423-1530
Practice Address - Country:US
Practice Address - Phone:845-222-9394
Practice Address - Fax:801-336-9639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-06
Last Update Date:2020-07-06
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
NJ1619904125OtherNPI