Provider Demographics
NPI:1043294523
Name:LIFESPAN THERAPY & SPORTS REHAB LLC
Entity type:Organization
Organization Name:LIFESPAN THERAPY & SPORTS REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:MARCKS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:732-254-0090
Mailing Address - Street 1:PO BOX 4414
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-1614
Mailing Address - Country:US
Mailing Address - Phone:732-785-0040
Mailing Address - Fax:732-785-0265
Practice Address - Street 1:758 HIGHWAY 18
Practice Address - Street 2:STE 106
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-4910
Practice Address - Country:US
Practice Address - Phone:732-254-0090
Practice Address - Fax:732-254-2292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ078740Medicare ID - Type Unspecified