Provider Demographics
NPI:1487702791
Name:FOUR CORNERS PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:FOUR CORNERS PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:973-239-8889
Mailing Address - Street 1:17 HANOVER RD
Mailing Address - Street 2:BUILDING 300
Mailing Address - City:FLORHAM PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07932-1411
Mailing Address - Country:US
Mailing Address - Phone:973-845-2592
Mailing Address - Fax:973-845-2593
Practice Address - Street 1:17 HANOVER RD
Practice Address - Street 2:BUILDING 300
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932-1411
Practice Address - Country:US
Practice Address - Phone:973-845-2592
Practice Address - Fax:973-845-2593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA009512002251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ082962Medicare ID - Type UnspecifiedMEDICARE PROVIDER