Provider Demographics
NPI:1962551655
Name:SHORELINE PHYSICAL THERAPY AND SPORTS MEDICINE LLC
Entity type:Organization
Organization Name:SHORELINE PHYSICAL THERAPY AND SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOBOSZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:203-876-7316
Mailing Address - Street 1:60 COMMERCE PARK
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3506
Mailing Address - Country:US
Mailing Address - Phone:203-876-7316
Mailing Address - Fax:203-876-0041
Practice Address - Street 1:60 COMMERCE PARK
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3506
Practice Address - Country:US
Practice Address - Phone:203-876-7316
Practice Address - Fax:203-876-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1245261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080001245CT03OtherBLUE CROSS BLUE SHIELD
CT35501OtherCIGNA