Provider Demographics
NPI:1730216409
Name:SPEONK PHYSICAL THERAPY
Entity type:Organization
Organization Name:SPEONK PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:A
Authorized Official - Last Name:BANGER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:631-325-3400
Mailing Address - Street 1:100 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3519
Mailing Address - Country:US
Mailing Address - Phone:631-325-3400
Mailing Address - Fax:631-325-3407
Practice Address - Street 1:295 MONTAUK HIGHWAY
Practice Address - Street 2:VILLAGE SQUARE #12
Practice Address - City:SPEONK
Practice Address - State:NY
Practice Address - Zip Code:11972-0586
Practice Address - Country:US
Practice Address - Phone:631-325-3400
Practice Address - Fax:631-325-3407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0260201225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty