Basic Information
| Provider Information | |||||||||
| NPI: | 1639386998 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONGWOOD SPORTS THERAPY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 356 MIDDLE COUNTRY RD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | CORAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117274432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317162700 | ||||||||
| FaxNumber: | 6317162782 | ||||||||
| Practice Location | |||||||||
| Address1: | 356 MIDDLE COUNTRY RD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | CORAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117274432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317162700 | ||||||||
| FaxNumber: | 6317162782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 04/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | FLYNN | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6317162700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | 014526 | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.