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General NPI Number Information
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NPI Number | 1275033078
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Entity Type | Organization
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Legal Business Name | KORU PHYSICAL THERAPY AND WELLNESS, PLLC
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Dates
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Enumeration Date | 02/19/2018
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Last Update Date | 02/19/2018
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Provider Practice Location Address
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Address Line | 619 BRIGHTON AVE # 101
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City | PORTLAND
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State | ME
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Zip | 04102-2323
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Country | US
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Telephone | 207-358-8161
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Fax | 207-352-5111
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Provider Business Mailing Address
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Address Line | 14 LEONARD ST
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City | PORTLAND
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State | ME
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Zip | 04103-2513
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Country | US
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Telephone | 207-712-2222
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Fax |
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Authorized Official
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Title or Position | MANAGER, OWNER
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Name | ALLISON RENA LAMARRE POOLE
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Credential | PT
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Telephone | 207-358-8161
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | PT3294
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License Number State | ME
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