Provider Demographics
NPI:1982880951
Name:NORTHEAST RESTORATIVE PHYSICAL AND OCCUPATIONAL THERAPY SERVICES, PLLC
Entity type:Organization
Organization Name:NORTHEAST RESTORATIVE PHYSICAL AND OCCUPATIONAL THERAPY SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSS
Authorized Official - Middle Name:
Authorized Official - Last Name:L'HOMMEDIEU
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:631-477-6035
Mailing Address - Street 1:985 CARRINGTON RD
Mailing Address - Street 2:
Mailing Address - City:CUTCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11935-1624
Mailing Address - Country:US
Mailing Address - Phone:631-765-8069
Mailing Address - Fax:631-614-4291
Practice Address - Street 1:633 E MAIN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-7013
Practice Address - Country:US
Practice Address - Phone:631-477-6035
Practice Address - Fax:631-614-4291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-21
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011600261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ86091Medicare PIN