Provider Demographics
NPI:1043698566
Name:RALLISTAN, JOSEPH IGNACIO
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:IGNACIO
Last Name:RALLISTAN
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 1:14 PROVOST AVE
Mailing Address - Street 2:
Mailing Address - City:KEYPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07735-1023
Mailing Address - Country:US
Mailing Address - Phone:205-544-5143
Mailing Address - Fax:
Practice Address - Street 1:14 PROVOST AVE
Practice Address - Street 2:
Practice Address - City:KEYPORT
Practice Address - State:NJ
Practice Address - Zip Code:07735-1023
Practice Address - Country:US
Practice Address - Phone:205-544-5143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-16
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01608200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist