Provider Demographics
NPI:1811107733
Name:ENTISE, SERG MARI SANCHEZ (BSPT)
Entity type:Individual
Prefix:MR
First Name:SERG MARI
Middle Name:SANCHEZ
Last Name:ENTISE
Suffix:
Gender:M
Credentials:BSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 BROAD ST APT 406
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2373
Mailing Address - Country:US
Mailing Address - Phone:201-575-0070
Mailing Address - Fax:
Practice Address - Street 1:400 PASSAIC AVE
Practice Address - Street 2:APT 112
Practice Address - City:EAST NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07029-2852
Practice Address - Country:US
Practice Address - Phone:201-575-0070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00994400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist