Provider Demographics
NPI:1598051260
Name:PHYSIOCARE PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:PHYSIOCARE PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Other - Org Name:PHYSIOCARE PHYSICAL THERAPY AND SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:860-608-2773
Mailing Address - Street 1:11 CENTRE ST
Mailing Address - Street 2:SUITE 6&7
Mailing Address - City:SALEM
Mailing Address - State:CT
Mailing Address - Zip Code:06420-3844
Mailing Address - Country:US
Mailing Address - Phone:860-608-2773
Mailing Address - Fax:860-471-8388
Practice Address - Street 1:11 CENTRE ST
Practice Address - Street 2:SUITE 6&7
Practice Address - City:SALEM
Practice Address - State:CT
Practice Address - Zip Code:06420-3844
Practice Address - Country:US
Practice Address - Phone:860-608-2773
Practice Address - Fax:860-471-8388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-21
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006963225100000X
CT009704225100000X
CT004259225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004221868-02Medicaid
CT004221868-02Medicaid