Provider Demographics
NPI:1184934812
Name:MEDINA, ALVIN L (PT)
Entity type:Individual
Prefix:MR
First Name:ALVIN
Middle Name:L
Last Name:MEDINA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 MILL ST
Mailing Address - Street 2:UNIT H3
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109
Mailing Address - Country:US
Mailing Address - Phone:862-371-9149
Mailing Address - Fax:
Practice Address - Street 1:710 MILL ST
Practice Address - Street 2:UNIT H3
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109
Practice Address - Country:US
Practice Address - Phone:973-759-1494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019509225100000X
NJ40QA01341200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist