Healthcare Provider Details

I. General information

NPI: 1194826651
Provider Name (Legal Business Name): WADING RIVER PHYSICAL THERAPY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5958 ROUTE 25A
WADING RIVER NY
11792-2001
US

IV. Provider business mailing address

5958 ROUTE 25A
WADING RIVER NY
11792-2001
US

V. Phone/Fax

Practice location:
  • Phone: 631-929-8200
  • Fax: 631-929-8228
Mailing address:
  • Phone: 631-929-8200
  • Fax: 631-929-8228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. WALTER PAUL VANCURA
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: P.T.
Phone: 631-929-8200