Basic Information
| Provider Information | |||||||||
| NPI: | 1790769362 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WRENCH | ||||||||
| FirstName: | BARRY | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 430 INNOVATION DRIVE | ||||||||
| Address2: | |||||||||
| City: | BLAIRSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243434060 | ||||||||
| FaxNumber: | 7243434069 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 THOMAS ST | ||||||||
| Address2: | |||||||||
| City: | JERSEY SHORE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177401049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703981859 | ||||||||
| FaxNumber: | 5703981707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 02/06/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT016883 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT016883 | 01 | PA | PA STATE BOARD | OTHER |