1194705780 NPI number — MR. DALE L SWEET JR. PHYSICAL THERAPIST

Table of content: MR. DALE L SWEET JR. PHYSICAL THERAPIST (NPI 1194705780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194705780 NPI number — MR. DALE L SWEET JR. PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SWEET
Provider First Name:
DALE
Provider Middle Name:
L
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
M

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:
1194705780
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 MARINE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THOMASTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06787-1470
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-283-2316
Provider Business Mailing Address Fax Number:
860-283-6079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 MARINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THOMASTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06787-1470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-283-2316
Provider Business Practice Location Address Fax Number:
860-283-6079
Provider Enumeration Date:
01/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

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

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

  • Identifier: 004190758 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6109 . This is a "LICENSE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: ANTHEM BC/BS . This is a "PROVIDER ID NUMBER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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