Basic Information
| Provider Information | |||||||||
| NPI: | 1508926247 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BAY SPORTS AND PHYSICAL THERAPY, PC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1160 MONTAUK HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | COPIAGUE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318424606 | ||||||||
| FaxNumber: | 6318420803 | ||||||||
| Practice Location | |||||||||
| Address1: | 1160 MONTAUK HWY | ||||||||
| Address2: | |||||||||
| City: | COPIAGUE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117264904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318424606 | ||||||||
| FaxNumber: | 6318420803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 12/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | SALONIA | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | ANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6318424606 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PT, DSC,CSCS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 009181 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.