Provider Demographics
NPI:1548543044
Name:CHRIS PRENTISS PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:CHRIS PRENTISS PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:R
Authorized Official - Middle Name:CHRIS
Authorized Official - Last Name:PRENTISS
Authorized Official - Suffix:
Authorized Official - Credentials:PT,OCS,CERTMDT,CSCS
Authorized Official - Phone:631-462-0118
Mailing Address - Street 1:763 LARKFIELD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3131
Mailing Address - Country:US
Mailing Address - Phone:631-462-0118
Mailing Address - Fax:631-462-0827
Practice Address - Street 1:763 LARKFIELD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3131
Practice Address - Country:US
Practice Address - Phone:631-462-0118
Practice Address - Fax:631-462-0827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ70761Medicare UPIN