Provider Demographics
NPI:1942385513
Name:SPECTRUM PHYSICAL THERAPY & ATHLETIC TRAINING, LLC
Entity Type:Organization
Organization Name:SPECTRUM PHYSICAL THERAPY & ATHLETIC TRAINING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:R
Authorized Official - Last Name:ZACCONE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, SCS,
Authorized Official - Phone:201-937-3600
Mailing Address - Street 1:184 CENTRAL AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:OLD TAPPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-7360
Mailing Address - Country:US
Mailing Address - Phone:201-768-2099
Mailing Address - Fax:201-731-5192
Practice Address - Street 1:1203 RIVER RD
Practice Address - Street 2:SUITE 4
Practice Address - City:EDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:07020-1456
Practice Address - Country:US
Practice Address - Phone:201-937-3600
Practice Address - Fax:201-731-5192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01107700225100000X
NY0256111225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ097268OtherPTAN
NJ097268OtherPTAN