Provider Demographics
NPI:1568483881
Name:KELSAR PHYSICAL THERAPY
Entity Type:Organization
Organization Name:KELSAR PHYSICAL THERAPY
Other - Org Name:DIANE KANE-FOURNIER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KANE-FOURNIER
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:860-886-2042
Mailing Address - Street 1:606 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-6007
Mailing Address - Country:US
Mailing Address - Phone:860-886-2042
Mailing Address - Fax:860-885-1811
Practice Address - Street 1:606 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-6007
Practice Address - Country:US
Practice Address - Phone:860-886-2042
Practice Address - Fax:860-885-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02452Medicare UPIN