Provider Demographics
NPI:1952629214
Name:BUCKSPORT PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:BUCKSPORT PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:L
Authorized Official - Last Name:DE VERSTERRE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:207-469-0786
Mailing Address - Street 1:PO BOX 901
Mailing Address - Street 2:
Mailing Address - City:BUCKSPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04416-0901
Mailing Address - Country:US
Mailing Address - Phone:207-469-0786
Mailing Address - Fax:207-469-9975
Practice Address - Street 1:34 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:BUCKSPORT
Practice Address - State:ME
Practice Address - Zip Code:04416-0901
Practice Address - Country:US
Practice Address - Phone:207-469-0786
Practice Address - Fax:207-469-9975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-12
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2563320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEDE ME0658Medicare PIN