Provider Demographics
NPI:1396523585
Name:BEACH WELLNESS PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:BEACH WELLNESS PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVALLO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:516-330-9213
Mailing Address - Street 1:522 W BEECH ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-3010
Mailing Address - Country:US
Mailing Address - Phone:516-330-9213
Mailing Address - Fax:
Practice Address - Street 1:522 W BEECH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-3010
Practice Address - Country:US
Practice Address - Phone:516-330-9213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy