Provider Demographics
NPI:1770814089
Name:VANTAGE SPORTS AND REHAB, LLC
Entity Type:Organization
Organization Name:VANTAGE SPORTS AND REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DMITRY
Authorized Official - Middle Name:
Authorized Official - Last Name:VOLOSHINOV
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, STS
Authorized Official - Phone:413-283-8303
Mailing Address - Street 1:1581 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:MA
Mailing Address - Zip Code:01069-1232
Mailing Address - Country:US
Mailing Address - Phone:413-283-8303
Mailing Address - Fax:413-823-8304
Practice Address - Street 1:1581 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:MA
Practice Address - Zip Code:01069-1232
Practice Address - Country:US
Practice Address - Phone:413-283-8303
Practice Address - Fax:413-823-8304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA001014801Medicare PIN