Provider Demographics
NPI:1962011387
Name:ELEVATION PHYSICAL THERAPY
Entity Type:Organization
Organization Name:ELEVATION PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGHURST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-540-2840
Mailing Address - Street 1:348 WALKER HILL RD
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:ME
Mailing Address - Zip Code:04294-4619
Mailing Address - Country:US
Mailing Address - Phone:801-540-2840
Mailing Address - Fax:
Practice Address - Street 1:128 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:ME
Practice Address - Zip Code:04938-6937
Practice Address - Country:US
Practice Address - Phone:801-540-2840
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
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
1255763439OtherNPI