Provider Demographics
NPI:1205033081
Name:COLLINSVILLE PHYSICAL THERAPY & WELLNESS, LLC
Entity Type:Organization
Organization Name:COLLINSVILLE PHYSICAL THERAPY & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:ALBANESE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:845-615-1585
Mailing Address - Street 1:PO BOX 1007
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-8007
Mailing Address - Country:US
Mailing Address - Phone:845-615-1585
Mailing Address - Fax:845-615-1576
Practice Address - Street 1:101 UNITED DR
Practice Address - Street 2:SUITE 100
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-7434
Practice Address - Country:US
Practice Address - Phone:618-343-1122
Practice Address - Fax:618-343-1444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2012-11-02
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
IL215525Medicare PIN