Provider Demographics
NPI:1063609576
Name:TRI COUNTY HOME THERAPY LLC
Entity type:Organization
Organization Name:TRI COUNTY HOME THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:856-305-4268
Mailing Address - Street 1:313 BEEBE RUN RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-5680
Mailing Address - Country:US
Mailing Address - Phone:856-305-4268
Mailing Address - Fax:856-697-0071
Practice Address - Street 1:313 BEEBE RUN RD
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-5680
Practice Address - Country:US
Practice Address - Phone:856-305-4268
Practice Address - Fax:856-697-0071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00566300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA00566300OtherLICENSE
NJ40QA00566300OtherLICENSE