Provider Demographics
NPI:1649828005
Name:PHYSIOCARE PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Entity type:Organization
Organization Name:PHYSIOCARE PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:860-949-2561
Mailing Address - Street 1:11 CENTRE ST STE 7
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:CT
Mailing Address - Zip Code:06420-3845
Mailing Address - Country:US
Mailing Address - Phone:860-949-2561
Mailing Address - Fax:860-471-8388
Practice Address - Street 1:131 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:EAST LYME
Practice Address - State:CT
Practice Address - Zip Code:06333-1605
Practice Address - Country:US
Practice Address - Phone:860-949-2561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYSIOCARE PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty