Provider Demographics
NPI:1801133103
Name:HOBOKEN HOLISTIC PHYSICAL THERAPY AND SPORTS MEDICINE LLC
Entity type:Organization
Organization Name:HOBOKEN HOLISTIC PHYSICAL THERAPY AND SPORTS MEDICINE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:DIVINAGRACIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-993-9344
Mailing Address - Street 1:701 STATE ROUTE 440 SUITE 21
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304
Mailing Address - Country:US
Mailing Address - Phone:201-993-9344
Mailing Address - Fax:
Practice Address - Street 1:701 STATE ROUTE 440 SUITE 21
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304
Practice Address - Country:US
Practice Address - Phone:201-315-9859
Practice Address - Fax:201-433-4772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-08
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00093800171100000X
NJ40QA00953000225100000X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty