Provider Demographics
NPI:1376301614
Name:SUPREME PHYSICAL THERAPY AND WELLNESS REHABILITATION CENTER
Entity Type:Organization
Organization Name:SUPREME PHYSICAL THERAPY AND WELLNESS REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO- OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ILICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:475-328-0009
Mailing Address - Street 1:14 LAYDON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2704
Mailing Address - Country:US
Mailing Address - Phone:203-584-3748
Mailing Address - Fax:203-212-8528
Practice Address - Street 1:1825 BARNUM AVE STE 304
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-5333
Practice Address - Country:US
Practice Address - Phone:475-328-0009
Practice Address - Fax:203-212-8528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty