Provider Demographics
NPI:1952346355
Name:OPTIMUM ORTHOPEDICS PHYSICAL THERAPY & REHAB CENTER II LLC
Entity type:Organization
Organization Name:OPTIMUM ORTHOPEDICS PHYSICAL THERAPY & REHAB CENTER II LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:Q
Authorized Official - Last Name:CERULLO
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT, CSCS
Authorized Official - Phone:973-746-2424
Mailing Address - Street 1:ONE GREENWOOD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3617
Mailing Address - Country:US
Mailing Address - Phone:973-746-2424
Mailing Address - Fax:973-746-5030
Practice Address - Street 1:1 GREENWOOD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3649
Practice Address - Country:US
Practice Address - Phone:973-746-2424
Practice Address - Fax:973-746-5030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA10818225100000X
NJQA08619225100000X
NJTR01594225XH1200X
NJQA08051225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5524560001Medicare NSC
NJ067296Medicare PIN