Provider Demographics
NPI:1285722348
Name:BAKER VALLEY SPORTS & PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:BAKER VALLEY SPORTS & PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:HOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MPT
Authorized Official - Phone:603-536-7777
Mailing Address - Street 1:612 TENNEY MOUNTAIN HWY
Mailing Address - Street 2:UNIT 3, TENNEY MOUNTAIN PLAZA
Mailing Address - City:PLYMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03264-3155
Mailing Address - Country:US
Mailing Address - Phone:603-536-7777
Mailing Address - Fax:603-536-7787
Practice Address - Street 1:612 TENNEY MOUNTAIN HWY
Practice Address - Street 2:UNIT 3, TENNEY MOUNTAIN PLAZA
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-3155
Practice Address - Country:US
Practice Address - Phone:603-536-7777
Practice Address - Fax:603-536-7787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3075261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy