Provider Demographics
NPI:1679019996
Name:PORT IMPERIAL THERAPY GROUP LLC
Entity Type:Organization
Organization Name:PORT IMPERIAL THERAPY GROUP LLC
Other - Org Name:EXCHANGE PHYSICAL THERAPY GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:FULOP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-272-9400
Mailing Address - Street 1:500 AVE AT PORT IMPERIAL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:WEEHAWKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07086-6960
Mailing Address - Country:US
Mailing Address - Phone:201-272-9400
Mailing Address - Fax:201-272-9402
Practice Address - Street 1:500 AVE AT PORT IMPERIAL BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:WEEHAWKEN
Practice Address - State:NJ
Practice Address - Zip Code:07086-6960
Practice Address - Country:US
Practice Address - Phone:201-721-6130
Practice Address - Fax:201-918-6864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-10
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty