Provider Demographics
NPI:1710092101
Name:FRYEBURG PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:FRYEBURG PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:SLATER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:207-925-6803
Mailing Address - Street 1:5 S LOWER BAY RD
Mailing Address - Street 2:
Mailing Address - City:LOVELL
Mailing Address - State:ME
Mailing Address - Zip Code:04051-3536
Mailing Address - Country:US
Mailing Address - Phone:207-925-6803
Mailing Address - Fax:
Practice Address - Street 1:5 S LOWER BAY RD
Practice Address - Street 2:
Practice Address - City:LOVELL
Practice Address - State:ME
Practice Address - Zip Code:04051-3536
Practice Address - Country:US
Practice Address - Phone:207-925-6803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431991000Medicaid
MEME1329Medicare ID - Type Unspecified