Provider Demographics
NPI:1740577964
Name:KEVIN NORMAN KOPACK
Entity Type:Organization
Organization Name:KEVIN NORMAN KOPACK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:KOPACK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:973-227-4280
Mailing Address - Street 1:297 PASSAIC AVE
Mailing Address - Street 2:UNIT 3
Mailing Address - City:FAIRFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07004-2503
Mailing Address - Country:US
Mailing Address - Phone:973-227-4280
Mailing Address - Fax:973-227-4210
Practice Address - Street 1:297 PASSAIC AVE
Practice Address - Street 2:UNIT 3
Practice Address - City:FAIRFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07004-2503
Practice Address - Country:US
Practice Address - Phone:973-227-4280
Practice Address - Fax:973-227-4210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-08
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QAO0335300261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy