# SPORTS EXTRA PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1346296969
- **Authorized official:** MICHELE THERESA GILSENAN D.O. (PRACTICE OWNER)
- **Authorized official phone:** (732) 388-7300

## Contact information

- **Practice address:** 67 WALNUT AVE, SUITE 202, CLARK, NJ 07066-1640
- **Practice address phone:** (732) 388-7300
- **Practice address fax:** (732) 388-1330
- **Mailing address:** 67 WALNUT AVE, SUITE 202, CLARK, NJ 07066-1640
- **Mailing address phone:** (732) 388-7300
- **Mailing address fax:** (732) 388-1330

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207QS0010X | Sports Medicine (Family Medicine) Physician | — | NULL | Yes |
| 207QS0010X | Sports Medicine (Family Medicine) Physician | — | — | Yes |

## Other

- **Enumeration date:** 05/25/2006
- **Last updated:** 10/18/2007