Provider Demographics
NPI:1144513144
Name:ELM PARK PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:ELM PARK PHYSICAL THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSLOV
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:508-799-6538
Mailing Address - Street 1:111 ELM ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-1967
Mailing Address - Country:US
Mailing Address - Phone:508-799-6538
Mailing Address - Fax:508-799-5535
Practice Address - Street 1:111 ELM ST
Practice Address - Street 2:SUITE 103
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-1967
Practice Address - Country:US
Practice Address - Phone:508-799-6538
Practice Address - Fax:508-799-5535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty