Provider Demographics
NPI:1427677509
Name:GAME CHANGER PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:GAME CHANGER PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:PASTER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:732-740-5384
Mailing Address - Street 1:1215 WYCKOFF RD
Mailing Address - Street 2:
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07727-3914
Mailing Address - Country:US
Mailing Address - Phone:732-740-5384
Mailing Address - Fax:212-223-0198
Practice Address - Street 1:1215 WYCKOFF RD
Practice Address - Street 2:
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07727-3914
Practice Address - Country:US
Practice Address - Phone:732-740-5384
Practice Address - Fax:212-223-0198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA01688000OtherLICENSE