Healthcare Provider Details

I. General information

NPI: 1588779888
Provider Name (Legal Business Name): ADVANTAGE PHYSICAL THERAPY AND HUMAN PERFORMANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 03/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 BUSINESS ROUTE 4 SUITE 3
CENTER RUTLAND VT
05736-9731
US

IV. Provider business mailing address

279 BUSINESS ROUTE 4 SUITE 3
CENTER RUTLAND VT
05736-9731
US

V. Phone/Fax

Practice location:
  • Phone: 802-773-8600
  • Fax: 802-773-2200
Mailing address:
  • Phone: 802-773-8600
  • Fax: 802-773-2200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number040-0003188
License Number StateVT

VIII. Authorized Official

Name: SCOTT DAVID TOMMOLA
Title or Position: PRESIDENT/THERAPIST
Credential: MS PT
Phone: 802-773-8600