Provider Demographics
NPI:1063868172
Name:DAVIS PHYSICAL THERAPY & SPORTS REHAB
Entity type:Organization
Organization Name:DAVIS PHYSICAL THERAPY & SPORTS REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:609-694-8896
Mailing Address - Street 1:6 DUNCAN CT
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-8467
Mailing Address - Country:US
Mailing Address - Phone:609-760-9619
Mailing Address - Fax:609-953-1715
Practice Address - Street 1:320 EVESBORO MEDFORD RD
Practice Address - Street 2:SUITE 310
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-5733
Practice Address - Country:US
Practice Address - Phone:609-694-8896
Practice Address - Fax:609-953-1715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-06
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00883900261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy