Provider Demographics
NPI:1023782323
Name:MAVEN NORTHEAST BERGEN, LLC
Entity type:Organization
Organization Name:MAVEN NORTHEAST BERGEN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-800-0010
Mailing Address - Street 1:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07653-0125
Mailing Address - Country:US
Mailing Address - Phone:973-800-0010
Mailing Address - Fax:
Practice Address - Street 1:201 BROAD AVE # 2W
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1508
Practice Address - Country:US
Practice Address - Phone:201-977-4441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy