Healthcare Provider Details

I. General information

NPI: 1578646220
Provider Name (Legal Business Name): SPECTRUM PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 04/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL RD SUITE 112
EAST PATCHOGUE NY
11772-4821
US

IV. Provider business mailing address

100 HOSPITAL RD SUITE 112
EAST PATCHOGUE NY
11772-4821
US

V. Phone/Fax

Practice location:
  • Phone: 631-456-5512
  • Fax: 631-456-5514
Mailing address:
  • Phone: 631-456-5512
  • Fax: 631-456-5514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number022096-1
License Number StateNY

VIII. Authorized Official

Name: DR. GARY A WELCH
Title or Position: PRESIDENT
Credential: DPT
Phone: 631-456-5512