Provider Demographics
NPI:1114028636
Name:THERASPORTS PLUS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:THERASPORTS PLUS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:VANCURA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:631-543-2068
Mailing Address - Street 1:366 VETERANS MEMORIAL HWY
Mailing Address - Street 2:SUITE #2
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-4387
Mailing Address - Country:US
Mailing Address - Phone:631-543-2068
Mailing Address - Fax:631-543-2082
Practice Address - Street 1:366 VETERANS MEMORIAL HWY
Practice Address - Street 2:SUITE #2
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4387
Practice Address - Country:US
Practice Address - Phone:631-543-2068
Practice Address - Fax:631-543-2082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016205225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYHIPOther281045P
NYQB3403OtherEMP BC BS
NYQAWGB1Medicare PIN