Provider Demographics
NPI:1548441090
Name:VILLAGE STREET PHYSICAL THERAPY AND SPORTS MEDICINE P.C.
Entity type:Organization
Organization Name:VILLAGE STREET PHYSICAL THERAPY AND SPORTS MEDICINE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DUFRESNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-562-8140
Mailing Address - Street 1:12 VILLAGE ST
Mailing Address - Street 2:SUITE 10
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-3828
Mailing Address - Country:US
Mailing Address - Phone:203-562-8140
Mailing Address - Fax:
Practice Address - Street 1:12 VILLAGE ST
Practice Address - Street 2:SUITE 10
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-3828
Practice Address - Country:US
Practice Address - Phone:203-562-8140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTOV1735OtherHEALTHNET
CT7614976004OtherCIGNA
CT183259OtherWELLCARE
CT080002017CT01OtherBCBS
CT897715OtherAETNA
CTA531345OtherOXFORD
CT080002017CT01OtherBCBS
CT650013704Medicare PIN