Provider Demographics
NPI:1508926247
Name:SOUTH BAY SPORTS AND PHYSICAL THERAPY, PC.
Entity Type:Organization
Organization Name:SOUTH BAY SPORTS AND PHYSICAL THERAPY, PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:SALONIA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DSC,CSCS
Authorized Official - Phone:631-842-4606
Mailing Address - Street 1:1160 MONTAUK HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726
Mailing Address - Country:US
Mailing Address - Phone:631-842-4606
Mailing Address - Fax:631-842-0803
Practice Address - Street 1:1160 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726-4904
Practice Address - Country:US
Practice Address - Phone:631-842-4606
Practice Address - Fax:631-842-0803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009181225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQCW201Medicare UPIN
NYQCW201Medicare PIN