1104376680 NPI number — PROFESSIONAL OCCUPATIONAL & PHYSICAL THERAPY, PLLC

Table of content: (NPI 1104376680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104376680 NPI number — PROFESSIONAL OCCUPATIONAL & PHYSICAL THERAPY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL OCCUPATIONAL & 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:
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:
1104376680
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2019
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:
631-396-0865

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
390 STATE ROUTE 10 STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RANDOLPH
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07869-2141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-895-9925
Provider Business Practice Location Address Fax Number:
973-895-9927
Provider Enumeration Date:
10/10/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BRUSH
Authorized Official First Name:
KATHLLEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
631-359-5859

Provider Taxonomy Codes

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

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





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