Provider Demographics
NPI:1609047554
Name:FILLMORE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:FILLMORE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-567-2232
Mailing Address - Street 1:11039 DUGWAY RD
Mailing Address - Street 2:
Mailing Address - City:FILLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14735-8610
Mailing Address - Country:US
Mailing Address - Phone:585-567-2232
Mailing Address - Fax:585-567-2239
Practice Address - Street 1:11039 DUGWAY RD
Practice Address - Street 2:
Practice Address - City:FILLMORE
Practice Address - State:NY
Practice Address - Zip Code:14735-8610
Practice Address - Country:US
Practice Address - Phone:585-567-2232
Practice Address - Fax:585-567-2239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016210225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0391Medicare PIN