1841688470 NPI number — FRESH START PHYSICAL THERAPY, PLLC

Table of content: (NPI 1841688470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841688470 NPI number — FRESH START PHYSICAL THERAPY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FRESH START 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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1841688470
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
907 NORTH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYRACUSE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13206-1644
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-440-5953
Provider Business Mailing Address Fax Number:
315-476-9694

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
907 NORTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13206-1644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-440-5953
Provider Business Practice Location Address Fax Number:
315-476-9694
Provider Enumeration Date:
01/06/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DIORIO
Authorized Official First Name:
CHRISTINE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
315-440-5953

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  021917 , 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)