Provider Demographics
NPI:1346481561
Name:COPPOLA PHYSICAL THERAPY AND FITNESS GYM LLC
Entity Type:Organization
Organization Name:COPPOLA PHYSICAL THERAPY AND FITNESS GYM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER, PTA
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-315-9552
Mailing Address - Street 1:143 RAYMOND RD UNIT 8
Mailing Address - Street 2:
Mailing Address - City:CANDIA
Mailing Address - State:NH
Mailing Address - Zip Code:03034-2133
Mailing Address - Country:US
Mailing Address - Phone:603-483-3355
Mailing Address - Fax:603-483-3357
Practice Address - Street 1:143 RAYMOND RD UNIT 8
Practice Address - Street 2:
Practice Address - City:CANDIA
Practice Address - State:NH
Practice Address - Zip Code:03034-2133
Practice Address - Country:US
Practice Address - Phone:603-483-3355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-18
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
NH2164261QP2000X
NH0740261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty