1003090374 NPI number — ROBERT WILUTIS OCCUPATIONAL AND PHYSICAL THERAPY, PLLC

Table of content: (NPI 1003090374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003090374 NPI number — ROBERT WILUTIS OCCUPATIONAL AND PHYSICAL THERAPY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERT WILUTIS OCCUPATIONAL AND PHYSICAL THERAPY, PLLC
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:
1003090374
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
635 BELLE TERRE RD
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
PORT JEFFERSON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11777
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-331-3608
Provider Business Mailing Address Fax Number:
631-331-2392

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
74 COMMERCE DR
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
RIVERHEAD
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11901-3105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-331-3608
Provider Business Practice Location Address Fax Number:
631-331-2392
Provider Enumeration Date:
12/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILUTIS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
631-331-3608

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  008737 , 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: 4823760003 . This is a "DME NSC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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