Provider Demographics
NPI:1629426093
Name:NORTH JERSEY PHYSICAL THERAPY & WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:NORTH JERSEY PHYSICAL THERAPY & WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSONELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-340-1940
Mailing Address - Street 1:1373 BROAD ST STE 301
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-4200
Mailing Address - Country:US
Mailing Address - Phone:973-340-1940
Mailing Address - Fax:973-340-1947
Practice Address - Street 1:1373 BROAD ST STE 301
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-4200
Practice Address - Country:US
Practice Address - Phone:973-340-1940
Practice Address - Fax:973-340-1947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-26
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty