1114028636 NPI number — THERASPORTS PLUS PHYSICAL THERAPY

Table of content: (NPI 1114028636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114028636 NPI number — THERASPORTS PLUS PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THERASPORTS PLUS PHYSICAL THERAPY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114028636
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
366 VETERANS MEMORIAL HWY
Provider Second Line Business Mailing Address:
SUITE #2
Provider Business Mailing Address City Name:
COMMACK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11725-4387
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-543-2068
Provider Business Mailing Address Fax Number:
631-543-2082

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
366 VETERANS MEMORIAL HWY
Provider Second Line Business Practice Location Address:
SUITE #2
Provider Business Practice Location Address City Name:
COMMACK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11725-4387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-543-2068
Provider Business Practice Location Address Fax Number:
631-543-2082
Provider Enumeration Date:
09/26/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VANCURA
Authorized Official First Name:
WALTER
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
OWNER/PHYSICAL THERAPIST
Authorized Official Telephone Number:
631-543-2068

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  016205 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: HIP . This is a "281045P" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: QB3403 . This is a "EMP BC BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".