Provider Demographics
NPI:1770598419
Name:WATERFORD PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:WATERFORD PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WAITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-796-3400
Mailing Address - Street 1:991 ROUTE 19 N STE E
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16441-9739
Mailing Address - Country:US
Mailing Address - Phone:814-796-3400
Mailing Address - Fax:814-796-8533
Practice Address - Street 1:991 ROUTE 19 N STE E
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:PA
Practice Address - Zip Code:16441-9739
Practice Address - Country:US
Practice Address - Phone:814-796-3400
Practice Address - Fax:814-796-8533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017340310001Medicaid
103029Medicare PIN