Provider Demographics
NPI:1861864217
Name:LOGOS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:LOGOS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSAK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:732-641-3620
Mailing Address - Street 1:PO BOX 521
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08862-0521
Mailing Address - Country:US
Mailing Address - Phone:732-641-3620
Mailing Address - Fax:
Practice Address - Street 1:155 NEW BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:HOPELAWN
Practice Address - State:NJ
Practice Address - Zip Code:08861-4133
Practice Address - Country:US
Practice Address - Phone:732-641-3620
Practice Address - Fax:732-826-3613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-26
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01385300261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ207820YWZMedicare PIN