Healthcare Provider Details

I. General information

NPI: 1275241234
Provider Name (Legal Business Name): JUSTIN KIRK PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2022
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1181 AQUIDNECK AVE
MIDDLETOWN RI
02842-5255
US

IV. Provider business mailing address

1181 AQUIDNECK AVE
MIDDLETOWN RI
02842-5255
US

V. Phone/Fax

Practice location:
  • Phone: 401-845-0840
  • Fax:
Mailing address:
  • Phone: 401-845-0840
  • Fax: 401-845-0842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT04105
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number2305215471
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: