=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750754636
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROGRESSIVE PHYSICAL THERAPY OPTIONS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2015
-----------------------------------------------------
Last Update Date | 11/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 BLACK MEADOW RD
-----------------------------------------------------
City | CHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10918-2227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-227-8795
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 513
-----------------------------------------------------
City | CHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10918-0513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-227-8795
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | MR. DMITRY LIBMAN
-----------------------------------------------------
Credential | MSPT
-----------------------------------------------------
Telephone | 860-227-8795
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 029202
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------