Provider Demographics
NPI:1588779888
Name:ADVANTAGE PHYSICAL THERAPY AND HUMAN PERFORMANCE
Entity type:Organization
Organization Name:ADVANTAGE PHYSICAL THERAPY AND HUMAN PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:TOMMOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MS PT
Authorized Official - Phone:802-773-8600
Mailing Address - Street 1:279 BUSINESS ROUTE 4
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CENTER RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05736-9731
Mailing Address - Country:US
Mailing Address - Phone:802-773-8600
Mailing Address - Fax:802-773-2200
Practice Address - Street 1:279 BUSINESS ROUTE 4
Practice Address - Street 2:SUITE 3
Practice Address - City:CENTER RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05736-9731
Practice Address - Country:US
Practice Address - Phone:802-773-8600
Practice Address - Fax:802-773-2200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0003188225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTVN3106Medicare PIN