Provider Demographics
NPI:1154454296
Name:AQUASPORT PHYSICAL THERAPY, P.C.
Entity Type:Organization
Organization Name:AQUASPORT PHYSICAL THERAPY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT, ATC, CSCS
Authorized Official - Phone:610-676-0411
Mailing Address - Street 1:1570 EGYPT RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-1193
Mailing Address - Country:US
Mailing Address - Phone:610-676-0411
Mailing Address - Fax:610-676-0412
Practice Address - Street 1:1570 EGYPT RD
Practice Address - Street 2:SUITE 120
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-1193
Practice Address - Country:US
Practice Address - Phone:610-676-0411
Practice Address - Fax:610-676-0412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA396746Medicare ID - Type UnspecifiedGROUP ID