Provider Demographics
NPI:1699195461
Name:LIFESPAN PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:LIFESPAN PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NEHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:973-224-3108
Mailing Address - Street 1:700 PALISADIUM DR
Mailing Address - Street 2:
Mailing Address - City:CLIFFSIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010-3239
Mailing Address - Country:US
Mailing Address - Phone:973-224-3108
Mailing Address - Fax:
Practice Address - Street 1:700 PALISADIUM DR
Practice Address - Street 2:
Practice Address - City:CLIFFSIDE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07010-3239
Practice Address - Country:US
Practice Address - Phone:973-224-3108
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ348684Medicare PIN