Provider Demographics
NPI:1992009203
Name:FAST TRACK PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:FAST TRACK PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:LASER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:856-504-6930
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:SOMERDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:08083-0009
Mailing Address - Country:US
Mailing Address - Phone:856-504-6930
Mailing Address - Fax:856-504-6934
Practice Address - Street 1:700 S WHITE HORSE PIKE
Practice Address - Street 2:SUITE D
Practice Address - City:SOMERDALE
Practice Address - State:NJ
Practice Address - Zip Code:08083-1253
Practice Address - Country:US
Practice Address - Phone:856-504-6930
Practice Address - Fax:856-504-6934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-29
Last Update Date:2012-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01113200261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ086839YDU4Medicare PIN