Healthcare Provider Details

I. General information

NPI: 1346481561
Provider Name (Legal Business Name): COPPOLA PHYSICAL THERAPY AND FITNESS GYM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2009
Last Update Date: 06/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 RAYMOND RD UNIT 8
CANDIA NH
03034-2133
US

IV. Provider business mailing address

143 RAYMOND RD UNIT 8
CANDIA NH
03034-2133
US

V. Phone/Fax

Practice location:
  • Phone: 603-483-3355
  • Fax:
Mailing address:
  • Phone: 603-483-3355
  • Fax: 603-483-3357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number0740
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2164
License Number StateNH

VIII. Authorized Official

Name: STEVEN LAWRENCE GORDON
Title or Position: CO-OWNER, PTA
Credential:
Phone: 603-315-9552