Provider Demographics
NPI:1205283454
Name:KINGSTON SPINE & SPORT PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:KINGSTON SPINE & SPORT PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:G
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPT
Authorized Official - Phone:607-316-0987
Mailing Address - Street 1:PO BOX 1588
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0588
Mailing Address - Country:US
Mailing Address - Phone:570-288-1185
Mailing Address - Fax:570-288-2050
Practice Address - Street 1:310 MARKET ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5425
Practice Address - Country:US
Practice Address - Phone:570-288-1185
Practice Address - Fax:570-288-2050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT023101225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA525210Medicare PIN