Provider Demographics
NPI:1164579603
Name:VICTOR PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:VICTOR PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:CARPIN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:585-924-3250
Mailing Address - Street 1:274 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14564-1157
Mailing Address - Country:US
Mailing Address - Phone:585-924-3250
Mailing Address - Fax:585-924-5127
Practice Address - Street 1:274 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:NY
Practice Address - Zip Code:14564-1157
Practice Address - Country:US
Practice Address - Phone:585-924-3250
Practice Address - Fax:585-924-5127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019558225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY107162FTOtherPREFERRED CARE
NY7574307OtherAETNA
NYG0186893370OtherEXCELLUS BCBS
NY107162FTOtherPREFERRED CARE
NYBA0344Medicare ID - Type Unspecified