Provider Demographics
NPI:1669690087
Name:CHESHIRE PHYSICAL THERAPY & SPORTS MEDICINE, INC
Entity type:Organization
Organization Name:CHESHIRE PHYSICAL THERAPY & SPORTS MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:203-271-2928
Mailing Address - Street 1:475 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3164
Mailing Address - Country:US
Mailing Address - Phone:203-271-2928
Mailing Address - Fax:203-699-8445
Practice Address - Street 1:475 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-3164
Practice Address - Country:US
Practice Address - Phone:203-271-2928
Practice Address - Fax:203-699-8445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT02770174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004232469Medicaid
CT225100000XOtherTAXONOMY - NPPES
CTC01310Medicare PIN