=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265655013
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILBERT & ASSOCIATES PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2007
-----------------------------------------------------
Last Update Date | 10/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 195 W MAIN ST
-----------------------------------------------------
City | NEW BRITAIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06052-1318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-225-0674
-----------------------------------------------------
Fax | 860-223-3330
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 195 W MAIN ST
-----------------------------------------------------
City | NEW BRITAIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06052-1318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-225-0674
-----------------------------------------------------
Fax | 860-223-3330
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. KEITH WILBERT
-----------------------------------------------------
Credential | PHYSICAL THERAPIST
-----------------------------------------------------
Telephone | 860-225-0674
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 002360
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------