Provider Demographics
NPI:1316006216
Name:LEWISBORO PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:LEWISBORO PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:412-654-3212
Mailing Address - Street 1:990 PEACHTREE IND BLVD BOX 101
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-5257
Mailing Address - Country:US
Mailing Address - Phone:833-888-7868
Mailing Address - Fax:888-522-1279
Practice Address - Street 1:890 ROUTE 35
Practice Address - Street 2:
Practice Address - City:CROSS RIVER
Practice Address - State:NY
Practice Address - Zip Code:10518
Practice Address - Country:US
Practice Address - Phone:914-763-5941
Practice Address - Fax:914-763-5332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2019-10-08
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
NYQ63031Medicare UPIN