=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376661660
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TREPSICORE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2007
-----------------------------------------------------
Last Update Date | 10/17/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 161 MANCHESTER RD
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-3402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-652-8131
-----------------------------------------------------
Fax | 860-812-2001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 161 MANCHESTER RD
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-3402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-652-8131
-----------------------------------------------------
Fax | 860-812-2001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | MS. ANNA CHAVEZ
-----------------------------------------------------
Credential | BS, PT
-----------------------------------------------------
Telephone | 860-918-1542
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 004526
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 004526
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------