Healthcare Provider Details

I. General information

NPI: 1578561171
Provider Name (Legal Business Name): MARK AUGUSTAUSKAS RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 11/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 HOLLEY LN 93 WATERBURY RD.
PROSPECT CT
06712-1484
US

IV. Provider business mailing address

21 HOLLEY LANE
PROSPECT CT
06712
US

V. Phone/Fax

Practice location:
  • Phone: 203-758-6569
  • Fax: 203-758-0443
Mailing address:
  • Phone: 203-758-6569
  • Fax: 203-758-0443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number002427
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: