MEDICARE: NORTHEAST SPINE & REHAB., 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

General Provider Information

NPI Number	:	1891733457
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST SPINE & REHAB., LLC

Provider Business Mailing Address
First Line	:	5520 PARK AVE
Second Line	:	SUITE 208
City	:	TRUMBULL
State	:	CT
Zip	:	06611-3463
Country	:	US
Telephone Number	:	203-368-1192
Fax Number	:	203-371-0358

Provider Business Practice Location Address
First Line	:	5520 PARK AVE
Second Line	:	SUITE 208
City	:	TRUMBULL
State	:	CT
Zip	:	06611-3463
Country	:	US
Telephone Number	:	203-368-1192
Fax Number	:	203-371-0358

Authorized Official
Title or Position	:	OFFICIAL
Name	:	MR. RONELL RONLEY OWENS
Credential	:
Telephone Number	:	203-368-1192

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	11/27/2007

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