Provider Demographics
NPI:1578936167
Name:SYNERGY PHYSICAL THERAPY AND WELLNESS
Entity Type:Organization
Organization Name:SYNERGY PHYSICAL THERAPY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KISHORE
Authorized Official - Middle Name:
Authorized Official - Last Name:KANDURI
Authorized Official - Suffix:
Authorized Official - Credentials:MR
Authorized Official - Phone:201-957-5864
Mailing Address - Street 1:400 ROUTE 211 E
Mailing Address - Street 2:SUITE 12
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-2122
Mailing Address - Country:US
Mailing Address - Phone:201-957-5864
Mailing Address - Fax:
Practice Address - Street 1:400 ROUTE 211 E
Practice Address - Street 2:SUITE 12
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2122
Practice Address - Country:US
Practice Address - Phone:201-957-5864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015851261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY015851OtherNY STATE PHYSICAL THERAPY LICENCE NUMBER
NY1740226281OtherINDIVIDUAL NPI