Provider Demographics
NPI:1952830960
Name:DEVINE PHYSICAL THERAPY, ACUPUNCTURE AND MASSAGE THERAPY, PLLC
Entity Type:Organization
Organization Name:DEVINE PHYSICAL THERAPY, ACUPUNCTURE AND MASSAGE THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:631-320-1100
Mailing Address - Street 1:PMB 373
Mailing Address - Street 2:186 SEVEN FARMS DRIVE, STE F
Mailing Address - City:DANIEL ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29492
Mailing Address - Country:US
Mailing Address - Phone:516-662-9962
Mailing Address - Fax:631-343-7174
Practice Address - Street 1:10 FORT SALONGA RD STE 2A
Practice Address - Street 2:
Practice Address - City:FORT SALONGA
Practice Address - State:NY
Practice Address - Zip Code:11768-1400
Practice Address - Country:US
Practice Address - Phone:631-320-1100
Practice Address - Fax:631-343-7174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-05
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty