Basic Information
| Provider Information | |||||||||
| NPI: | 1740208339 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICAL THERAPY AND WELLNESS INSTITUTE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1311 MAMARONECK AVE STE 140 | ||||||||
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| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106055224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142944050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 730 S BROAD ST | ||||||||
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| City: | LANSDALE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194465211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158559871 | ||||||||
| FaxNumber: | 2158558748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | RUCKER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9147778700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225100000X | DAPT000285 | PA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2078464000 | 01 | PA | IBC KEYSTONE HMO | OTHER | 001384752 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 7798359 | 01 | PA | AETNA PPO | OTHER |