Provider Demographics
NPI:1770098634
Name:716 PHYSICAL THERAPY, PLLC
Entity type:Organization
Organization Name:716 PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOERGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:716-560-3290
Mailing Address - Street 1:4591 SOUTHWESTERN BLVD APT FF4
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-7706
Mailing Address - Country:US
Mailing Address - Phone:716-560-3290
Mailing Address - Fax:
Practice Address - Street 1:4931 LAKE SHORE RD STE 300
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-5662
Practice Address - Country:US
Practice Address - Phone:716-560-3290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036600208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty