Provider Demographics
NPI:1700283884
Name:ST. MINA THERAPEUTICS LLC
Entity Type:Organization
Organization Name:ST. MINA THERAPEUTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSAK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:732-641-3620
Mailing Address - Street 1:PO BOX 521
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08862-0521
Mailing Address - Country:US
Mailing Address - Phone:732-641-3620
Mailing Address - Fax:732-826-3613
Practice Address - Street 1:418 SMITH ST
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-3829
Practice Address - Country:US
Practice Address - Phone:732-641-3620
Practice Address - Fax:732-826-3613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ60099622OtherNJ HEALTH