Provider Demographics
NPI:1861677262
Name:ADVANCED PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:ADVANCED PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:203-879-0107
Mailing Address - Street 1:465 WOLCOTT RD
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716-2613
Mailing Address - Country:US
Mailing Address - Phone:203-879-0107
Mailing Address - Fax:203-879-0206
Practice Address - Street 1:465 WOLCOTT RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-2613
Practice Address - Country:US
Practice Address - Phone:203-879-0107
Practice Address - Fax:203-879-0206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2015-01-21
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
CT0121902OtherORTHONET
CT613042400OtherDEPARTMENT OF LABOR
CTC03848Medicare PIN