Provider Demographics
NPI:1336234558
Name:REHAB EXCELLENCE CENTER-MOUNT LAUREL LLC
Entity Type:Organization
Organization Name:REHAB EXCELLENCE CENTER-MOUNT LAUREL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LARA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:VIGGIANO LOCASCIO
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:609-265-0700
Mailing Address - Street 1:100 CREEK CROSSING BOULEVARD, SUITE 107
Mailing Address - Street 2:
Mailing Address - City:HAINESPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:08036
Mailing Address - Country:US
Mailing Address - Phone:609-265-0700
Mailing Address - Fax:609-265-0708
Practice Address - Street 1:100 CREEK CROSSING BOULEVARD, SUITE 107
Practice Address - Street 2:
Practice Address - City:HAINESPORT
Practice Address - State:NJ
Practice Address - Zip Code:08036
Practice Address - Country:US
Practice Address - Phone:609-265-0700
Practice Address - Fax:609-265-0708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00900100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ083127Medicare ID - Type Unspecified