Basic Information
| Provider Information | |||||||||
| NPI: | 1174254940 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OAK TREE PHYSICAL THERAPY CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LEWISBORO PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 104 | ||||||||
| Address2: | |||||||||
| City: | CROSS RIVER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105180104 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 876 ROUTE 35 | ||||||||
| Address2: | |||||||||
| City: | CROSS RIVER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9147635941 | ||||||||
| FaxNumber: | 9142058390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2022 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SWEENEY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9149079713 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OAK TREE PHYSICAL THERAPY | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MSPT | ||||||||
| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.