Provider Demographics
NPI:1831801596
Name:PANDA PHYSICAL MEDICINE LLC
Entity type:Organization
Organization Name:PANDA PHYSICAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JILLIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROVIRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:848-220-4685
Mailing Address - Street 1:904 DEAL RD APT 12
Mailing Address - Street 2:
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-3443
Mailing Address - Country:US
Mailing Address - Phone:732-455-1375
Mailing Address - Fax:
Practice Address - Street 1:142 HIGHWAY 35 STE 107
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-1864
Practice Address - Country:US
Practice Address - Phone:732-867-8030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty