Provider Demographics
NPI:1144980962
Name:HEALTH AQUATIC WELLNESS OF CHAUTAUQUA PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:HEALTH AQUATIC WELLNESS OF CHAUTAUQUA PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:RISTAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-688-6119
Mailing Address - Street 1:3266 FLUVANNA AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:FLUVANNA
Mailing Address - State:NY
Mailing Address - Zip Code:14701-9706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3266 FLUVANNA AVENUE EXT
Practice Address - Street 2:
Practice Address - City:FLUVANNA
Practice Address - State:NY
Practice Address - Zip Code:14701-9706
Practice Address - Country:US
Practice Address - Phone:716-708-6179
Practice Address - Fax:716-463-2228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-20
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty