Basic Information
| Provider Information | |||||||||
| NPI: | 1548874035 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONNECTICUT LUNA CARE PHYSICAL THERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5800 LONETREE BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | ROCKLIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 957653785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668396979 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5800 LONETREE BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | ROCKLIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 957653785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778396979 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2020 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| AuthorizedOfficialLastName: | ODELL | ||||||||
| AuthorizedOfficialFirstName: | CLARISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PAYER DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6508670522 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.