=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134222003
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEAK PHYSICAL THERAPY ,WEST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 726 E MAIN ST SUITE 101
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10940-2653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-344-0168
-----------------------------------------------------
Fax | 845-341-0472
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 726 E MAIN ST SUITE 101
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10940-2653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-344-0168
-----------------------------------------------------
Fax | 845-341-0472
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | PATRICK ROSSILLO
-----------------------------------------------------
Credential | P.T., CHT
-----------------------------------------------------
Telephone | 845-344-0168
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 012916-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------