Provider Demographics
NPI:1750480471
Name:PERFECT FORMATION PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PERFECT FORMATION PHYSICAL THERAPY
Other - Org Name:PERFORM PT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORINNE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SICOLA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:908-874-4522
Mailing Address - Street 1:411 US HIGHWAY 206
Mailing Address - Street 2:SUITE 16
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NJ
Mailing Address - Zip Code:08844-5024
Mailing Address - Country:US
Mailing Address - Phone:908-874-4522
Mailing Address - Fax:908-874-4531
Practice Address - Street 1:411 US HIGHWAY 206
Practice Address - Street 2:SUITE 16
Practice Address - City:HILLSBOROUGH
Practice Address - State:NJ
Practice Address - Zip Code:08844-5024
Practice Address - Country:US
Practice Address - Phone:908-874-4522
Practice Address - Fax:908-874-4531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00926000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ065683Medicare ID - Type Unspecified