Provider Demographics
NPI:1073591764
Name:PRENTISS, R CHRIS (PT,OCS,CERTMDT,CSCS)
Entity Type:Individual
Prefix:MR
First Name:R
Middle Name:CHRIS
Last Name:PRENTISS
Suffix:
Gender:M
Credentials:PT,OCS,CERTMDT,CSCS
Other - Prefix:MR
Other - First Name:R
Other - Middle Name:CHRIS
Other - Last Name:PRENTISS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT,OCS,CERTMDT,CSCS
Mailing Address - Street 1:763 LARKFIELD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3131
Mailing Address - Country:US
Mailing Address - Phone:631-462-0118
Mailing Address - Fax:631-462-0827
Practice Address - Street 1:763 LARKFIELD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3131
Practice Address - Country:US
Practice Address - Phone:631-462-0118
Practice Address - Fax:631-462-0827
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011690225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ70761Medicare UPIN