Provider Demographics
NPI:1649677964
Name:ST CHARLES REHABILITATION
Entity type:Organization
Organization Name:ST CHARLES REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENDON
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:NOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:631-312-2834
Mailing Address - Street 1:77 ROUTE 112 STE F
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-1230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:77 ROUTE 112 STE F
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1230
Practice Address - Country:US
Practice Address - Phone:631-207-2370
Practice Address - Fax:631-758-1748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038336283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital