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General NPI Number Information
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NPI Number | 1497887756
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Entity Type | Organization
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Legal Business Name | PORT JEFFERSON PHYSICAL THERAPY PC
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Dates
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Enumeration Date | 03/12/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 300 HALLOCK AVE
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-1227
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Country | US
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Telephone | 631-331-1070
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Fax | 631-331-1126
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Provider Business Mailing Address
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Address Line | 300 HALLOCK AVE
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-1227
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Country | US
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Telephone | 631-331-1070
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Fax | 631-331-1126
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Authorized Official
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Title or Position | OWNER
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Name | MR. ROGER W WETSELL
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Credential | PHYSICAL THERAPIST
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Telephone | 631-331-1070
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | 002266
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License Number State | NY
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