Basic Information
| Provider Information | |||||||||
| NPI: | 1316006216 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LEWISBORO PHYSICAL THERAPY PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 990 PEACHTREE IND BLVD BOX 101 | ||||||||
| Address2: | |||||||||
| City: | SUWANEE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300245257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8338887868 | ||||||||
| FaxNumber: | 8885221279 | ||||||||
| Practice Location | |||||||||
| Address1: | 890 ROUTE 35 | ||||||||
| Address2: | |||||||||
| City: | CROSS RIVER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9147635941 | ||||||||
| FaxNumber: | 9147635332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 10/08/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WATERS | ||||||||
| AuthorizedOfficialFirstName: | SEAN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4126543212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.S., P.T. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.