Provider Demographics
NPI:1396893590
Name:PHYSICAL THERAPY CENTER OF BRISTOL, LLC
Entity type:Organization
Organization Name:PHYSICAL THERAPY CENTER OF BRISTOL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:ELDON
Authorized Official - Last Name:DOUGLASS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:941-870-4401
Mailing Address - Street 1:9070 W CHEYENNE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-8935
Mailing Address - Country:US
Mailing Address - Phone:702-818-5000
Mailing Address - Fax:702-818-5001
Practice Address - Street 1:72 PINE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-6960
Practice Address - Country:US
Practice Address - Phone:860-585-5800
Practice Address - Fax:860-585-5840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-07
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03019Medicare ID - Type Unspecified