Provider Demographics
NPI:1659667970
Name:EAST BRUNSWICK REHABILITATION LLC
Entity Type:Organization
Organization Name:EAST BRUNSWICK REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:BORISOV
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:718-368-0100
Mailing Address - Street 1:65 RUES LANE
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-4240
Mailing Address - Country:US
Mailing Address - Phone:732-257-4444
Mailing Address - Fax:732-257-9799
Practice Address - Street 1:65 RUES LN
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-4240
Practice Address - Country:US
Practice Address - Phone:718-368-0100
Practice Address - Fax:718-368-1208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-24
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07870200208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty