1508393786 NPI number — FOLSOM PHYSICAL THERAPY, LLC

Table of content: MR. TIMOTHY ERVIN GEORGE JR. US NAVY IDC (NPI 1689821977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508393786 NPI number — FOLSOM PHYSICAL THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOLSOM PHYSICAL THERAPY, LLC
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:
6
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:
1508393786
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 UNION ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOPSHAM
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04086-1946
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-841-0120
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 INDUSTRIAL PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04011-7314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-841-0120
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2017

Additional Information

Authorized Official

Authorized Official Last Name:
FOLSOM
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PHYSICAL THERAPIST/OWNER
Authorized Official Telephone Number:
207-841-0120

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT1177 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 254270099 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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