Provider Demographics
NPI:1558860809
Name:SPECTRUM PHYSICAL THERAPY & ATHLETIC TRAINING, LLC
Entity type:Organization
Organization Name:SPECTRUM PHYSICAL THERAPY & ATHLETIC TRAINING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:ZACCONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-768-2000
Mailing Address - Street 1:184 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:OLD TAPPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-7360
Mailing Address - Country:US
Mailing Address - Phone:201-768-2000
Mailing Address - Fax:
Practice Address - Street 1:184 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:OLD TAPPAN
Practice Address - State:NJ
Practice Address - Zip Code:07675-7360
Practice Address - Country:US
Practice Address - Phone:201-768-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECTRUM PHYSICAL THERAPY & ATHLETIC TRAINING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-02-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherTAX ID