Provider Demographics
NPI:1073678447
Name:ORTHOPEDIC & SPORTS PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:ORTHOPEDIC & SPORTS PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:P.T.OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:COLE
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:315-698-9353
Mailing Address - Street 1:5586 LEGIONNAIRE DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-3504
Mailing Address - Country:US
Mailing Address - Phone:315-698-9353
Mailing Address - Fax:315-698-4463
Practice Address - Street 1:5586 LEGIONNAIRE DR
Practice Address - Street 2:SUITE 6
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-3504
Practice Address - Country:US
Practice Address - Phone:315-698-9353
Practice Address - Fax:315-698-4463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012257-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty