Provider Demographics
NPI:1972923506
Name:GORELOV, ISAAK
Entity type:Individual
Prefix:
First Name:ISAAK
Middle Name:
Last Name:GORELOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 NORTH CORPORATE DRIVE
Mailing Address - Street 2:PUSH TO WALK
Mailing Address - City:RIVERDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07457
Mailing Address - Country:US
Mailing Address - Phone:862-200-5848
Mailing Address - Fax:862-200-5976
Practice Address - Street 1:6 NORTH CORPORATE DRIVE
Practice Address - Street 2:PUSH TO WALK
Practice Address - City:RIVERDALE
Practice Address - State:NJ
Practice Address - Zip Code:07457
Practice Address - Country:US
Practice Address - Phone:862-200-5848
Practice Address - Fax:862-200-5976
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ726999225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner