Provider Demographics
NPI:1972936417
Name:INDIGO AQUATIC THERAPY LLC
Entity Type:Organization
Organization Name:INDIGO AQUATIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:973-949-3927
Mailing Address - Street 1:599 GOFFLE HILL RD
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07506-3037
Mailing Address - Country:US
Mailing Address - Phone:973-949-3927
Mailing Address - Fax:
Practice Address - Street 1:599 GOFFLE HILL RD
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NJ
Practice Address - Zip Code:07506-3037
Practice Address - Country:US
Practice Address - Phone:973-949-3927
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-20
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01348800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty