Provider Demographics
NPI:1295838688
Name:PREMIER PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PREMIER PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:WENZEL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:860-436-6772
Mailing Address - Street 1:3 DEER PATH
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067
Mailing Address - Country:US
Mailing Address - Phone:860-436-6772
Mailing Address - Fax:860-436-6772
Practice Address - Street 1:3 DEER PATH
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067
Practice Address - Country:US
Practice Address - Phone:860-436-6772
Practice Address - Fax:860-436-6772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006301225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03344Medicare ID - Type Unspecified