Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 40QA00989800 | NJ |
NPI | 1083663926 |
---|---|
Provider Name | Mr. Glenn David Prettitore |
First Address | Glen Rock, NJ 07452-1708 |
Second Address | Glen Rock, NJ 07452-1708 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/05/2006 |
Last Update Date | 19/04/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
058169 | MEDCARE PROVIDER NUMBER (01) | NJ |