Provider Demographics
NPI:1407083686
Name:JEFFERSON SPORTS & PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:JEFFERSON SPORTS & PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:HEIM
Authorized Official - Suffix:
Authorized Official - Credentials:PTMS
Authorized Official - Phone:631-928-2277
Mailing Address - Street 1:460 COUNTY ROAD 111
Mailing Address - Street 2:#15
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949
Mailing Address - Country:US
Mailing Address - Phone:631-909-8712
Mailing Address - Fax:631-909-8714
Practice Address - Street 1:460 COUNTY ROAD 111
Practice Address - Street 2:#15
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949
Practice Address - Country:US
Practice Address - Phone:631-909-8712
Practice Address - Fax:631-909-8714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-16
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007458225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty