Provider Demographics
NPI:1457692220
Name:REGAL PHYSICAL THERAPY
Entity Type:Organization
Organization Name:REGAL PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:KOSIBA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:631-495-9968
Mailing Address - Street 1:33 NEAL PATH
Mailing Address - Street 2:
Mailing Address - City:SOUTH SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11720-4503
Mailing Address - Country:US
Mailing Address - Phone:631-495-9968
Mailing Address - Fax:631-980-3543
Practice Address - Street 1:33 NEAL PATH
Practice Address - Street 2:
Practice Address - City:SOUTH SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11720-4503
Practice Address - Country:US
Practice Address - Phone:631-495-9968
Practice Address - Fax:631-980-3543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-04
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015470225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty