Provider Demographics
NPI:1023158433
Name:REHAB PRO PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:REHAB PRO PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERWIN
Authorized Official - Middle Name:RENEGADO
Authorized Official - Last Name:BANDALES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:973-773-9990
Mailing Address - Street 1:975 CLIFTON AVENUE
Mailing Address - Street 2:STE 2
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013
Mailing Address - Country:US
Mailing Address - Phone:973-773-9990
Mailing Address - Fax:973-773-7772
Practice Address - Street 1:975 CLIFTON AVENUE
Practice Address - Street 2:STE 2
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013
Practice Address - Country:US
Practice Address - Phone:973-773-9990
Practice Address - Fax:973-773-7772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00672700225100000X
NJ40QA01013300225100000X
NJ40QA00655900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
088310Medicare ID - Type Unspecified