Provider Demographics
NPI:1164448049
Name:PLEASANT VALLEY PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:PLEASANT VALLEY PHYSICAL THERAPY LLC
Other - Org Name:LAGRANGE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:DIBERNARDO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:845-471-2423
Mailing Address - Street 1:1100 ROUTE 55
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LA GRANGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12540
Mailing Address - Country:US
Mailing Address - Phone:845-471-2423
Mailing Address - Fax:845-471-2776
Practice Address - Street 1:1100 ROUTE 55
Practice Address - Street 2:SUITE 101
Practice Address - City:LA GRANGEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12540
Practice Address - Country:US
Practice Address - Phone:845-471-2423
Practice Address - Fax:845-471-2776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016283-1225100000X
NY018803-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5376010001Medicare NSC
NYQDW621Medicare ID - Type Unspecified