Provider Demographics
NPI:1841686474
Name:PONDVILLE PHYSICAL THERAPY
Entity type:Organization
Organization Name:PONDVILLE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:781-706-7574
Mailing Address - Street 1:31 PINE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NORFOLK
Mailing Address - State:MA
Mailing Address - Zip Code:02056-1642
Mailing Address - Country:US
Mailing Address - Phone:508-623-3700
Mailing Address - Fax:
Practice Address - Street 1:31 PINE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:NORFOLK
Practice Address - State:MA
Practice Address - Zip Code:02056-1642
Practice Address - Country:US
Practice Address - Phone:508-623-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PONDVILLE MEDICAL ASSOCIATES, LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6041225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty