Provider Demographics
NPI:1962565424
Name:RANDOLPH REHABILITATION CENTER
Entity type:Organization
Organization Name:RANDOLPH REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TANIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-366-7413
Mailing Address - Street 1:588 ROUTE 10 WEST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869
Mailing Address - Country:US
Mailing Address - Phone:973-366-7413
Mailing Address - Fax:973-366-9427
Practice Address - Street 1:588 ROUTE 10 WEST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869
Practice Address - Country:US
Practice Address - Phone:973-366-7413
Practice Address - Fax:973-366-9427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01039500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
067015Medicare ID - Type Unspecified