Provider Demographics
NPI:1386659779
Name:PATCHOGUE PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:PATCHOGUE PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIERAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DENEEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:631-447-9211
Mailing Address - Street 1:54 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3002
Mailing Address - Country:US
Mailing Address - Phone:631-447-9211
Mailing Address - Fax:631-447-9214
Practice Address - Street 1:54 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3002
Practice Address - Country:US
Practice Address - Phone:631-447-9211
Practice Address - Fax:631-447-9214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015188-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty