Provider Demographics
NPI:1255793550
Name:BUFFALO TELETHERAPY LLC
Entity type:Organization
Organization Name:BUFFALO TELETHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:716-949-8202
Mailing Address - Street 1:258 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14222-1706
Mailing Address - Country:US
Mailing Address - Phone:716-949-8202
Mailing Address - Fax:
Practice Address - Street 1:258 ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222-1706
Practice Address - Country:US
Practice Address - Phone:716-949-8202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-25
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028310225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1194818401OtherNPI