Provider Demographics
NPI:1629116249
Name:FARMINGTON VALLEY PHYSICAL THERAPY AND SPORTS MEDICINE, PC
Entity Type:Organization
Organization Name:FARMINGTON VALLEY PHYSICAL THERAPY AND SPORTS MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BOGUSLAWA
Authorized Official - Middle Name:JOLANTA
Authorized Official - Last Name:BADON
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:860-673-0223
Mailing Address - Street 1:112 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:UNIONVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06085-1255
Mailing Address - Country:US
Mailing Address - Phone:860-673-0223
Mailing Address - Fax:860-673-7605
Practice Address - Street 1:112 S MAIN ST
Practice Address - Street 2:
Practice Address - City:UNIONVILLE
Practice Address - State:CT
Practice Address - Zip Code:06085-1255
Practice Address - Country:US
Practice Address - Phone:860-673-0223
Practice Address - Fax:860-673-7605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-03
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004916261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT076568Medicare ID - Type UnspecifiedMEDICARE