Provider Demographics
NPI:1831260504
Name:THREE VILLAGE PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:THREE VILLAGE PHYSICAL THERAPY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:PT,CFMT
Authorized Official - Phone:631-355-2120
Mailing Address - Street 1:6 OUTPOST LN
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29928-3802
Mailing Address - Country:US
Mailing Address - Phone:631-355-2120
Mailing Address - Fax:843-686-4000
Practice Address - Street 1:97 MAIN ST
Practice Address - Street 2:SUITE F
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-1937
Practice Address - Country:US
Practice Address - Phone:631-355-2120
Practice Address - Fax:843-686-4000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2013-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014253-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ3WKJ1Medicare PIN
SCQ35096Medicare PIN