Healthcare Provider Details

I. General information

NPI: 1013155746
Provider Name (Legal Business Name): ULTRA HEALTH PT & PTA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2009
Last Update Date: 02/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 BRENTWOOD RD SUITE B
BAY SHORE NY
11706-6923
US

IV. Provider business mailing address

53 BRENTWOOD RD SUITE B
BAY SHORE NY
11706-6923
US

V. Phone/Fax

Practice location:
  • Phone: 631-328-5920
  • Fax: 631-328-5921
Mailing address:
  • Phone: 631-328-5920
  • Fax: 631-328-5921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number021499-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number003072-1
License Number StateNY

VIII. Authorized Official

Name: MR. EDWARD W KALTEN JR.
Title or Position: OWNER/DIRECTOR
Credential: PT
Phone: 631-328-5920