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General NPI Number Information
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NPI Number | 1376301614
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Entity Type | Organization
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Legal Business Name | SUPREME PHYSICAL THERAPY AND WELLNESS REHABILITATION CENTER
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Dates
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Enumeration Date | 03/11/2024
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Last Update Date | 03/11/2024
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Provider Practice Location Address
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Address Line | 1825 BARNUM AVE STE 304
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City | STRATFORD
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State | CT
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Zip | 06614-5333
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Country | US
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Telephone | 475-328-0009
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Fax | 203-212-8528
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Provider Business Mailing Address
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Address Line | 14 LAYDON AVE
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City | NORTH HAVEN
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State | CT
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Zip | 06473-2704
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Country | US
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Telephone | 203-584-3748
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Fax | 203-212-8528
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Authorized Official
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Title or Position | CO- OWNER
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Name | DR. ILICIA MATHIS
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Credential | DPT
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Telephone | 475-328-0009
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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