1902195506 NPI number — AGEWELL SOUTH PHYSICAL THERAPY AND WELLNESS PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902195506 NPI number — AGEWELL SOUTH PHYSICAL THERAPY AND WELLNESS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AGEWELL SOUTH PHYSICAL THERAPY AND WELLNESS PA
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:
6
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:
1902195506
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
223 RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUGLASTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11363-1308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-318-1304
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5180 W ATLANTIC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELRAY BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33484-8103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-318-1304
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/04/2011

Additional Information

Authorized Official

Authorized Official Last Name:
DRAGAN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
914-318-1304

Provider Taxonomy Codes

  • Taxonomy code: 2251G0304X , with the licence number:  PT 26314 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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