Provider Demographics
NPI:1558431239
Name:MULTISPORT PHYSICAL THERAPY & FITNESS PLLC
Entity Type:Organization
Organization Name:MULTISPORT PHYSICAL THERAPY & FITNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:PROSSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-451-2270
Mailing Address - Street 1:304 FIRST ST
Mailing Address - Street 2:MULTISPORT PHYSICAL THERAPY & FITNESS PLLC
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088
Mailing Address - Country:US
Mailing Address - Phone:315-451-2270
Mailing Address - Fax:315-451-2271
Practice Address - Street 1:304 FIRST ST
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088
Practice Address - Country:US
Practice Address - Phone:315-451-2270
Practice Address - Fax:315-451-2271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01791225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0433Medicare ID - Type Unspecified