=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467966168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILLER PLACE PHYSICAL THERAPY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2017
-----------------------------------------------------
Last Update Date | 11/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41 ECHO AVE
-----------------------------------------------------
City | MILLER PLACE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11764-2108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-331-2348
-----------------------------------------------------
Fax | 631-928-7068
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 ECHO AVE
-----------------------------------------------------
City | MILLER PLACE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11764-2108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-553-8370
-----------------------------------------------------
Fax | 631-928-7068
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR OF PHYSICAL THERAPY
-----------------------------------------------------
Name | DR. DONALD A MCCREA
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 631-331-2348
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 011801
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------