Provider Demographics
NPI:1124108782
Name:ACTIVITY FIRST PHYSICAL THERAPY AND SPORTS MEDICINE
Entity type:Organization
Organization Name:ACTIVITY FIRST PHYSICAL THERAPY AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:732-544-0007
Mailing Address - Street 1:158 WYCKOFF RD
Mailing Address - Street 2:
Mailing Address - City:EATONTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-1840
Mailing Address - Country:US
Mailing Address - Phone:732-544-0007
Mailing Address - Fax:732-544-0008
Practice Address - Street 1:158 WYCKOFF RD
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-1840
Practice Address - Country:US
Practice Address - Phone:732-544-0007
Practice Address - Fax:732-544-0008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00616100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty