Healthcare Provider Details

I. General information

NPI: 1780986539
Provider Name (Legal Business Name): PLYMOUTH REGIONAL REHABILITATION SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2010
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 LAKE ST
BRISTOL NH
03222-4548
US

IV. Provider business mailing address

60 LYME ST
OLD LYME CT
06371-2332
US

V. Phone/Fax

Practice location:
  • Phone: 603-744-0275
  • Fax: 603-744-9378
Mailing address:
  • Phone: 860-434-9398
  • Fax: 860-434-0739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL FORTUNATO
Title or Position: VP FINANCE
Credential:
Phone: 860-434-9398