Provider Demographics
NPI:1639319122
Name:LONG ISLAND PREMIER PHYSICAL & AQUATIC THERAPY LLC
Entity Type:Organization
Organization Name:LONG ISLAND PREMIER PHYSICAL & AQUATIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:SPAHN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:631-991-3311
Mailing Address - Street 1:155 W SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-2434
Mailing Address - Country:US
Mailing Address - Phone:631-991-3311
Mailing Address - Fax:
Practice Address - Street 1:155 W SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-2435
Practice Address - Country:US
Practice Address - Phone:631-991-3311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-24
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029010-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ076C1OtherBCBS