Basic Information
| Provider Information | |||||||||
| NPI: | 1629244421 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LANCASTER DEPEW CHEEKTOWAGA PHYSICAL THERAPY,PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ELMA MARILLA PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3260 WALDEN AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DEPEW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140432842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166510100 | ||||||||
| FaxNumber: | 7166510151 | ||||||||
| Practice Location | |||||||||
| Address1: | 3260 WALDEN AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DEPEW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140432842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166510100 | ||||||||
| FaxNumber: | 7166510151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2008 | ||||||||
| LastUpdateDate: | 05/01/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TRAVIS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | DOUGLAS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7166510100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| 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.