Provider Demographics
NPI:1124751748
Name:ALTIUS PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:ALTIUS PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRACCONERI
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:845-548-1641
Mailing Address - Street 1:769 DRAKE LN
Mailing Address - Street 2:
Mailing Address - City:RIVER VALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-6115
Mailing Address - Country:US
Mailing Address - Phone:845-548-1641
Mailing Address - Fax:
Practice Address - Street 1:52 PARK AVE STE A4
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07656-1277
Practice Address - Country:US
Practice Address - Phone:845-548-1641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-01
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy