1336299700 NPI number — ON TRACK PHYSICAL THERAPY, LLC

Table of content: (NPI 1336299700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336299700 NPI number — ON TRACK PHYSICAL THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ON TRACK 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:
1336299700
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 PLAZA DR
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
VESTAL
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13850-3640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-797-5414
Provider Business Mailing Address Fax Number:
607-797-6537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 PLAZA DR
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
VESTAL
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13850-3640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-797-5414
Provider Business Practice Location Address Fax Number:
607-797-6537
Provider Enumeration Date:
01/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOISVERT
Authorized Official First Name:
LOUIS
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
607-797-5414

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  008038-1 , 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: S791 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 6697064 . This is a "GHI PPO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7782695 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 166468 . This is a "EXCELLUS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 3949264 . This is a "AETNA HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02721415 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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