Provider Demographics
NPI:1962925412
Name:PROVERE PHYSICAL THERAPY - PARAMUS LLC
Entity type:Organization
Organization Name:PROVERE PHYSICAL THERAPY - PARAMUS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CEDRIC
Authorized Official - Middle Name:
Authorized Official - Last Name:HADDAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-538-7131
Mailing Address - Street 1:637 WYCKOFF AVE PMB 361
Mailing Address - Street 2:
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-1438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:407 SETTE DR BLDG E
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-2940
Practice Address - Country:US
Practice Address - Phone:201-538-7131
Practice Address - Fax:201-538-7131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE