Provider Demographics
NPI:1790231611
Name:SILVER LAKE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:SILVER LAKE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT/CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:UMALI-DIZON
Authorized Official - Suffix:
Authorized Official - Credentials:PT,DPT
Authorized Official - Phone:973-751-9230
Mailing Address - Street 1:9-11 CUOZZO ST.
Mailing Address - Street 2:FLOOR 1
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-1231
Mailing Address - Country:US
Mailing Address - Phone:916-849-8761
Mailing Address - Fax:
Practice Address - Street 1:140 BELMONT AVE
Practice Address - Street 2:STE. 101
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-1018
Practice Address - Country:US
Practice Address - Phone:973-751-9230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01114300261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy