Provider Demographics
NPI:1528351988
Name:PREMIER PHYSICAL THERAPY OF LONG ISLAND PC
Entity type:Organization
Organization Name:PREMIER PHYSICAL THERAPY OF LONG ISLAND PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ANGELILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:111-111-1111
Mailing Address - Street 1:84 PACIFIC BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-4700
Mailing Address - Country:US
Mailing Address - Phone:516-698-2930
Mailing Address - Fax:
Practice Address - Street 1:1 TERRY ST
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1720
Practice Address - Country:US
Practice Address - Phone:111-111-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024794225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty