1760601942 NPI number — PRO PHYSICAL THERAPY & SPORTSCARE, INC.

Table of content: (NPI 1760601942)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760601942 NPI number — PRO PHYSICAL THERAPY & SPORTSCARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRO PHYSICAL THERAPY & SPORTSCARE, INC.
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:
1760601942
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 FALL RIVER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEEKONK
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02771-5506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-336-3121
Provider Business Mailing Address Fax Number:
508-336-3120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 FALL RIVER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEEKONK
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02771-5506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-336-3121
Provider Business Practice Location Address Fax Number:
508-336-3120
Provider Enumeration Date:
04/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LECLAIRE
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER AND PHYSICAL THERAPIST
Authorized Official Telephone Number:
508-336-3121

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT00460 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 8100 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Y61010 . This is a "BLUE CROSS BLUE SHIELD MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2520-9 . This is a "BLUE CROSS BLUE SHIELD RI" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 402383 . This is a "BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 43142951 . This is a "HEALTHCARE VALUE MGMT" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 64-00067 . This is a "UNITED HEALTH" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 608183 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 605708 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 102722300 . This is a "DEPT OF LABOR ACS" identifier . This identifiers is of the category "OTHER".
  • Identifier: PR35723 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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