Provider Demographics
NPI:1679775506
Name:PAYNE, CARL ADRIAN (ATC)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:ADRIAN
Last Name:PAYNE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 MOUNTAINSIDE DR
Mailing Address - Street 2:
Mailing Address - City:POMPTON LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07442-1757
Mailing Address - Country:US
Mailing Address - Phone:973-616-4872
Mailing Address - Fax:
Practice Address - Street 1:467 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3425
Practice Address - Country:US
Practice Address - Phone:973-748-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT001120002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer