Provider Demographics
NPI:1629355490
Name:COSTA PHYSICAL THERAPY, P.C.
Entity Type:Organization
Organization Name:COSTA PHYSICAL THERAPY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:COSTA
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:631-724-3150
Mailing Address - Street 1:269 E MAIN ST
Mailing Address - Street 2:SUITE E3
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2832
Mailing Address - Country:US
Mailing Address - Phone:631-724-3150
Mailing Address - Fax:631-724-3117
Practice Address - Street 1:269 E MAIN ST
Practice Address - Street 2:SUITE E3
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2832
Practice Address - Country:US
Practice Address - Phone:631-724-3150
Practice Address - Fax:631-724-3117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009869174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty