Provider Demographics
NPI:1811097306
Name:COMPLETE REHABILITATION AND SPORTS PHYSICAL THERAPY, PC
Entity type:Organization
Organization Name:COMPLETE REHABILITATION AND SPORTS PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MS,PT
Authorized Official - Phone:631-585-5915
Mailing Address - Street 1:15 HAWKINS AVE
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-5832
Mailing Address - Country:US
Mailing Address - Phone:631-585-5915
Mailing Address - Fax:631-585-5916
Practice Address - Street 1:15 HAWKINS AVE
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-5832
Practice Address - Country:US
Practice Address - Phone:631-585-5915
Practice Address - Fax:631-585-5916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022363225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQL6511Medicare ID - Type Unspecified