Provider Demographics
NPI:1396897773
Name:PEDIATRIC REHABILITATION OF NORTH JERSEY PC
Entity type:Organization
Organization Name:PEDIATRIC REHABILITATION OF NORTH JERSEY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MUCCIO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:973-628-1300
Mailing Address - Street 1:309 BLACK OAK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-6504
Mailing Address - Country:US
Mailing Address - Phone:973-628-1300
Mailing Address - Fax:973-628-0300
Practice Address - Street 1:309 BLACK OAK RIDGE RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-6504
Practice Address - Country:US
Practice Address - Phone:973-628-1300
Practice Address - Fax:973-628-0300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00794200261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)