Provider Demographics
NPI:1518088723
Name:STRIDE PHYSICAL THERAPY AND PEDORTHIC CENTER, PC
Entity Type:Organization
Organization Name:STRIDE PHYSICAL THERAPY AND PEDORTHIC CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:T
Authorized Official - Last Name:NOLE
Authorized Official - Suffix:
Authorized Official - Credentials:MA PT CPC
Authorized Official - Phone:203-758-8307
Mailing Address - Street 1:80 TURNPIKE DR
Mailing Address - Street 2:UNIT 1
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-1830
Mailing Address - Country:US
Mailing Address - Phone:203-758-8307
Mailing Address - Fax:203-758-8394
Practice Address - Street 1:80 TURNPIKE DR
Practice Address - Street 2:UNIT 1
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-1830
Practice Address - Country:US
Practice Address - Phone:203-758-8307
Practice Address - Fax:203-758-8394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003621332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004137338Medicaid
CT080003621CT02OtherANTHEM
CT004137338Medicaid