Provider Demographics
NPI:1770025157
Name:BRIGANTINE PHYSICAL THERAPY AND FITNESS LLC
Entity Type:Organization
Organization Name:BRIGANTINE PHYSICAL THERAPY AND FITNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:DANAHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-373-3767
Mailing Address - Street 1:312 S 26TH ST
Mailing Address - Street 2:
Mailing Address - City:BRIGANTINE
Mailing Address - State:NJ
Mailing Address - Zip Code:08203-1845
Mailing Address - Country:US
Mailing Address - Phone:302-373-3767
Mailing Address - Fax:
Practice Address - Street 1:3103 W BRIGANTINE AVE
Practice Address - Street 2:
Practice Address - City:BRIGANTINE
Practice Address - State:NJ
Practice Address - Zip Code:08203-1655
Practice Address - Country:US
Practice Address - Phone:302-373-3767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-16
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01663000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1104229244Medicaid
DE1104229244Medicare NSC