1194549105 NPI number — ELEVATION PHYSICAL THERAPY & PERFORMANCE PLLC MAURICE DISLEY SOLE MBR

Table of content: (NPI 1194549105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194549105 NPI number — ELEVATION PHYSICAL THERAPY & PERFORMANCE PLLC MAURICE DISLEY SOLE MBR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELEVATION PHYSICAL THERAPY & PERFORMANCE PLLC MAURICE DISLEY SOLE MBR
Provider Last Name:
Provider First Name:
Provider Middle Name:
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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:
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NPI Number Information

NPI Number:
1194549105
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
58 BURNETT ST APT 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANBY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01033-3312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-285-4015
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
340 MCKINSTRY AVE STE 250
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICOPEE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01013-1849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-285-4015
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/15/2024

Additional Information

Authorized Official

Authorized Official Last Name:
DISLEY
Authorized Official First Name:
MAURICE
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
413-285-4015

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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