1952830960 NPI number — DEVINE PHYSICAL THERAPY, ACUPUNCTURE AND MASSAGE THERAPY, PLLC

Table of content: (NPI 1952830960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952830960 NPI number — DEVINE PHYSICAL THERAPY, ACUPUNCTURE AND MASSAGE THERAPY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEVINE PHYSICAL THERAPY, ACUPUNCTURE AND MASSAGE THERAPY, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
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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:
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NPI Number Information

NPI Number:
1952830960
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PMB 373
Provider Second Line Business Mailing Address:
186 SEVEN FARMS DRIVE, STE F
Provider Business Mailing Address City Name:
DANIEL ISLAND
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29492
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-662-9962
Provider Business Mailing Address Fax Number:
631-343-7174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 FORT SALONGA RD STE 2A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SALONGA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11768-1400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-320-1100
Provider Business Practice Location Address Fax Number:
631-343-7174
Provider Enumeration Date:
06/05/2017

Additional Information

Authorized Official

Authorized Official Last Name:
OLSEN
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
631-320-1100

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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