Provider Demographics
NPI:1659774875
Name:THE RECOVERY ROOM PHYSICAL THERAPY AND ATHLETIC CENTER
Entity Type:Organization
Organization Name:THE RECOVERY ROOM PHYSICAL THERAPY AND ATHLETIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VIDAIC
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, CSCS
Authorized Official - Phone:201-264-8652
Mailing Address - Street 1:425 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ORADELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07649-1717
Mailing Address - Country:US
Mailing Address - Phone:201-264-8652
Mailing Address - Fax:
Practice Address - Street 1:681 LAWLINS RD
Practice Address - Street 2:
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-1449
Practice Address - Country:US
Practice Address - Phone:201-885-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00904900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty