MEDICARE: SEABLUE PHYSICAL THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center		ME

General Provider Information

NPI Number	:	1528389319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEABLUE PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	PO BOX 165
Second Line	:
City	:	LINCOLNVILLE
State	:	ME
Zip	:	04849-0165
Country	:	US
Telephone Number	:	207-706-6076
Fax Number	:	877-807-8994

Provider Business Practice Location Address
First Line	:	67 ATLANTIC HWY
Second Line	:
City	:	NORTHPORT
State	:	ME
Zip	:	04849
Country	:	US
Telephone Number	:	207-706-6076
Fax Number	:	877-807-8994

Authorized Official
Title or Position	:	OWNER/PHYSICAL THERAPIST
Name	:	MR. BRAD RAYMOND OLSEN
Credential	:
Telephone Number	:	207-706-6076

Provider Enumeration Date	:	06/16/2010
Last Update Date	:	06/16/2010

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