Healthcare Provider Details

I. General information

NPI: 1265650188
Provider Name (Legal Business Name): BOLTON PHYSICAL THERAPY & SPORTS PERFORMANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 BOSTON TURNPIKE
BOLTON CT
06043
US

IV. Provider business mailing address

PO BOX 9518
BOLTON CT
06043-9518
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-8758
  • Fax: 860-646-0256
Mailing address:
  • Phone: 860-646-8758
  • Fax: 860-646-0256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number005532
License Number StateCT

VIII. Authorized Official

Name: MR. BRUCE ALAN LANGEVIN
Title or Position: OWNER
Credential: PHYSICAL THERAPIST
Phone: 860-646-8758