Provider Demographics
NPI:1073680641
Name:LIFESTYLE PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:LIFESTYLE PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:MEYERS
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:631-360-0313
Mailing Address - Street 1:309 E MAIN ST
Mailing Address - Street 2:STE 202
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2844
Mailing Address - Country:US
Mailing Address - Phone:631-360-0313
Mailing Address - Fax:
Practice Address - Street 1:309 E MAIN ST
Practice Address - Street 2:STE 202
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2844
Practice Address - Country:US
Practice Address - Phone:631-360-0313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0085701225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01914570Medicaid
NYQ06L61Medicare ID - Type Unspecified