Provider Demographics
NPI:1538580907
Name:GERIACTIVE, LLC
Entity type:Organization
Organization Name:GERIACTIVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDOLIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-644-8096
Mailing Address - Street 1:215 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07417-1222
Mailing Address - Country:US
Mailing Address - Phone:201-644-8096
Mailing Address - Fax:
Practice Address - Street 1:215 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07417-1222
Practice Address - Country:US
Practice Address - Phone:201-644-8096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-02
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty