Provider Demographics
NPI:1013082817
Name:ADVANTAGE PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:ADVANTAGE PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:860-683-1007
Mailing Address - Street 1:340 BROAD ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-3030
Mailing Address - Country:US
Mailing Address - Phone:860-683-1007
Mailing Address - Fax:860-683-1154
Practice Address - Street 1:340 BROAD ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-3030
Practice Address - Country:US
Practice Address - Phone:860-683-1007
Practice Address - Fax:860-683-1154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy