=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235551318
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRESCRIBED MOTION PT FITNESS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2014
-----------------------------------------------------
Last Update Date | 01/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5629 MAIN ST STUDIO 203
-----------------------------------------------------
City | WILLIAMSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14221-5450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-359-6316
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5629 MAIN ST STUDIO 203
-----------------------------------------------------
City | WILLIAMSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14221-5450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | PAUL WHISSEL
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 716-359-6316
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 036724
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------