Provider Demographics
NPI:1912381906
Name:PIVOT PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PIVOT PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETRUCCELLI
Authorized Official - Suffix:II
Authorized Official - Credentials:PT, DPT, SCS, OCS
Authorized Official - Phone:302-504-6195
Mailing Address - Street 1:4512 KIRKWOOD HWY
Mailing Address - Street 2:STE. 303
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-5123
Mailing Address - Country:US
Mailing Address - Phone:302-504-6195
Mailing Address - Fax:302-504-6194
Practice Address - Street 1:4512 KIRKWOOD HWY
Practice Address - Street 2:STE. 303
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-5123
Practice Address - Country:US
Practice Address - Phone:302-504-6195
Practice Address - Fax:302-504-6194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0003344261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy