Provider Demographics
NPI:1679638456
Name:WALK WELL SUMMIT LLC
Entity Type:Organization
Organization Name:WALK WELL SUMMIT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROONEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:908-766-4737
Mailing Address - Street 1:413 SPRINGFIELD AVE
Mailing Address - Street 2:WALKWELL SUMMIT, LLC
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-2603
Mailing Address - Country:US
Mailing Address - Phone:908-273-7979
Mailing Address - Fax:908-273-7617
Practice Address - Street 1:413 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-2603
Practice Address - Country:US
Practice Address - Phone:908-273-7979
Practice Address - Fax:908-273-7617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ224L00000X
NJ335E00000X335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthistGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7830408Medicaid
7465030001Medicare NSC