Provider Demographics
NPI:1952669335
Name:PREMIER PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:PREMIER PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:JON
Authorized Official - Last Name:GWALTNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:401-596-1616
Mailing Address - Street 1:50 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-3402
Mailing Address - Country:US
Mailing Address - Phone:401-596-1616
Mailing Address - Fax:401-596-1650
Practice Address - Street 1:50 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-3402
Practice Address - Country:US
Practice Address - Phone:401-596-1616
Practice Address - Fax:401-596-1650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI01993225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty