Provider Demographics
NPI:1811528151
Name:AQUA PURA LIMITED LIABILITY COMPANY
Entity type:Organization
Organization Name:AQUA PURA LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:D'ANGELO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-748-8341
Mailing Address - Street 1:3 CARPENDER RD
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1501
Mailing Address - Country:US
Mailing Address - Phone:732-545-5771
Mailing Address - Fax:
Practice Address - Street 1:191 BRADLEY AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-5166
Practice Address - Country:US
Practice Address - Phone:917-748-8341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY195391OtherLICENSE