1083694145 NPI number — KAISER PHYSICAL THERAPY PC

Table of content: (NPI 1083694145)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083694145 NPI number — KAISER PHYSICAL THERAPY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KAISER PHYSICAL THERAPY PC
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:
THE SOURCE FOR HEALTH & WELL LIVING
Provider Other Organization Name Type Code:
5
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:
1083694145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 ELM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST AURORA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14052-2535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-652-1803
Provider Business Mailing Address Fax Number:
716-652-1951

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 ELM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST AURORA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14052-2535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-652-1803
Provider Business Practice Location Address Fax Number:
716-652-1951
Provider Enumeration Date:
01/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KAISER
Authorized Official First Name:
SETH
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
OWNER AND PRESIDENT
Authorized Official Telephone Number:
716-652-1803

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  6160 , 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: 00020087901 . This is a "UNIV" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 002084681 . This is a "BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: AA1030 . This is a "MEDICARE ID- TYPE UNSPECIFIED" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 006084683 . This is a "BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 9303777 . This is a "IA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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