Provider Demographics
NPI:1417163817
Name:ADVANCE PHYSICAL THERAPY & SPORT REHAB
Entity Type:Organization
Organization Name:ADVANCE PHYSICAL THERAPY & SPORT REHAB
Other - Org Name:PHYSICAL THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT,SCS,CSCS,EMT
Authorized Official - Phone:781-592-0540
Mailing Address - Street 1:1 MARKET ST 3RD FLOOR
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01901
Mailing Address - Country:US
Mailing Address - Phone:781-593-5797
Mailing Address - Fax:
Practice Address - Street 1:1 MARKET ST STE 3
Practice Address - Street 2:39 CROSS STREET SUITE#205,PEABODY,MA 01960
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1044
Practice Address - Country:US
Practice Address - Phone:781-592-0540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6761305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service