1205830973 NPI number — LEE PHYSICAL THERAPY WELLNESS LLC

Table of content: (NPI 1205830973)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205830973 NPI number — LEE PHYSICAL THERAPY WELLNESS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEE PHYSICAL THERAPY WELLNESS 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:
LEE PHYSICAL THERAPY & WELLNESS LLC
Provider Other Organization Name Type Code:
4
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:
1205830973
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1244
Provider Second Line Business Mailing Address:
348 MAIN STREET
Provider Business Mailing Address City Name:
CAIRO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-622-9200
Provider Business Mailing Address Fax Number:
518-622-9945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
348 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAIRO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-622-9200
Provider Business Practice Location Address Fax Number:
518-622-9945
Provider Enumeration Date:
06/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
KATRINA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER/SINGLE MEMBER/PHYSICAL THERAP
Authorized Official Telephone Number:
518-622-9200

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: 02369877 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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