Provider Demographics
NPI:1023742772
Name:LIFT BRIDGE PHYSICAL THERAPY, PLLC
Entity type:Organization
Organization Name:LIFT BRIDGE PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:COLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RICCIONE
Authorized Official - Suffix:
Authorized Official - Credentials:MS PT
Authorized Official - Phone:585-797-5308
Mailing Address - Street 1:52 WINCANTON DR
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-3847
Mailing Address - Country:US
Mailing Address - Phone:585-797-5308
Mailing Address - Fax:
Practice Address - Street 1:52 WINCANTON DR
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-3847
Practice Address - Country:US
Practice Address - Phone:585-797-5308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-10
Last Update Date:2022-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1265599252Medicaid