=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144707274
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXTEND REHAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2018
-----------------------------------------------------
Last Update Date | 02/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 CODFISH HILL RD
-----------------------------------------------------
City | BETHEL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06801-3203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 475-279-0347
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 121 CODFISH HILL RD
-----------------------------------------------------
City | BETHEL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06801-3203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 475-279-0347
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | STEPHEN SURIANO
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 475-279-0838
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------