Healthcare Provider Details

I. General information

NPI: 1639367295
Provider Name (Legal Business Name): FAMILY CARE PHYSICIAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 ALLEN ST
SPRINGFIELD MA
01118-1803
US

IV. Provider business mailing address

1515 ALLEN ST
SPRINGFIELD MA
01118-1803
US

V. Phone/Fax

Practice location:
  • Phone: 413-783-9114
  • Fax: 413-782-6074
Mailing address:
  • Phone: 413-783-9114
  • Fax: 413-782-6074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number7165
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierY61118
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBLUE CROSS/BLUE SHIELD

VIII. Authorized Official

Name: PATRICIA ANN DETOMAS
Title or Position: FINANCIAL ADMINISTRATOR
Credential:
Phone: 413-782-6074