Provider Demographics
NPI:1093115404
Name:CORE BALANCE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:CORE BALANCE PHYSICAL THERAPY, LLC
Other - Org Name:CORE BALANCE PHYSICAL THERAPY, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:COLONNA
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:845-269-9475
Mailing Address - Street 1:22 KNAPP ST
Mailing Address - Street 2:SUITE 303
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06907-1700
Mailing Address - Country:US
Mailing Address - Phone:203-433-0869
Mailing Address - Fax:203-989-3959
Practice Address - Street 1:22 KNAPP ST
Practice Address - Street 2:SUITE 303
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06907-1700
Practice Address - Country:US
Practice Address - Phone:203-433-0869
Practice Address - Fax:203-989-3959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-04
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0087062251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400267161Medicare UPIN