Provider Demographics
NPI:1265297642
Name:IDENTITY PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:IDENTITY PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSZKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:973-577-5921
Mailing Address - Street 1:593 S LIVINGSTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039
Mailing Address - Country:US
Mailing Address - Phone:973-577-5921
Mailing Address - Fax:888-686-2968
Practice Address - Street 1:593 S LIVINGSTON AVENUE
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-0703
Practice Address - Country:US
Practice Address - Phone:973-577-5921
Practice Address - Fax:888-686-2968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty