Provider Demographics
NPI:1376728501
Name:SOUTH FORK PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:SOUTH FORK PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT PARTNER PT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:DORICE
Authorized Official - Last Name:BARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:516-680-3172
Mailing Address - Street 1:PO BOX 95
Mailing Address - Street 2:
Mailing Address - City:SAGAPONACK
Mailing Address - State:NY
Mailing Address - Zip Code:11962-0095
Mailing Address - Country:US
Mailing Address - Phone:516-680-3172
Mailing Address - Fax:631-537-7187
Practice Address - Street 1:73 SCOTLINE DRIVE
Practice Address - Street 2:
Practice Address - City:SAGAPONACK
Practice Address - State:NY
Practice Address - Zip Code:11962-0095
Practice Address - Country:US
Practice Address - Phone:516-680-3172
Practice Address - Fax:631-537-7187
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH FORK PHYSICAL THERAPY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-07
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ0WLW1Medicare PIN