=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740371707
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA LYNN BROADWELL PHYSICAL THERAPIST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 882 MASON ST
-----------------------------------------------------
City | MORRISONVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12962-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-561-6888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 882 MASON ST
-----------------------------------------------------
City | MORRISONVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12962-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-561-6888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 008917-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------