Provider Demographics
NPI:1427454966
Name:AVBADEVBORO, NELSON
Entity type:Individual
Prefix:
First Name:NELSON
Middle Name:
Last Name:AVBADEVBORO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07071-2437
Mailing Address - Country:US
Mailing Address - Phone:347-665-5629
Mailing Address - Fax:
Practice Address - Street 1:710 MILL ST
Practice Address - Street 2:UNIT H3
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-5318
Practice Address - Country:US
Practice Address - Phone:973-759-1494
Practice Address - Fax:973-759-0557
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00292100225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant