Provider Demographics
NPI:1174704159
Name:POST ROAD PHYSICAL THERAPY & SPORTS MEDICINE CLINIC, LLC
Entity type:Organization
Organization Name:POST ROAD PHYSICAL THERAPY & SPORTS MEDICINE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PARE
Authorized Official - Suffix:
Authorized Official - Credentials:PT,AT,C
Authorized Official - Phone:860-664-0366
Mailing Address - Street 1:246 E MAIN ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:CLINTON
Mailing Address - State:CT
Mailing Address - Zip Code:06413-2245
Mailing Address - Country:US
Mailing Address - Phone:860-664-0366
Mailing Address - Fax:
Practice Address - Street 1:246 E MAIN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:CLINTON
Practice Address - State:CT
Practice Address - Zip Code:06413-2245
Practice Address - Country:US
Practice Address - Phone:860-664-0366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3248261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03380Medicare PIN