1831190453 NPI number — PROEX PHYSICAL THERAPY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831190453 NPI number — PROEX PHYSICAL THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROEX 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:
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:
1831190453
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
576 BROADHOLLOW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11747-5002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-359-5859
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 TRADE CENTER
Provider Second Line Business Practice Location Address:
SUITE 1650
Provider Business Practice Location Address City Name:
WOBURN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-935-2655
Provider Business Practice Location Address Fax Number:
781-395-9097
Provider Enumeration Date:
08/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WILKINSON
Authorized Official First Name:
KERRI
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER OF CREDENTIALING
Authorized Official Telephone Number:
631-359-5589

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: Y61376 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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