MEDICARE: ULTRA HEALTH PT & PTA, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	003072-1	NY
2	225100000X	Physical Therapist	021499-1	NY

General Provider Information

NPI Number	:	1013155746
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ULTRA HEALTH PT & PTA, PLLC

Provider Business Mailing Address
First Line	:	53 BRENTWOOD RD
Second Line	:	SUITE B
City	:	BAY SHORE
State	:	NY
Zip	:	11706-6923
Country	:	US
Telephone Number	:	631-328-5920
Fax Number	:	631-328-5921

Provider Business Practice Location Address
First Line	:	53 BRENTWOOD RD
Second Line	:	SUITE B
City	:	BAY SHORE
State	:	NY
Zip	:	11706-6923
Country	:	US
Telephone Number	:	631-328-5920
Fax Number	:	631-328-5921

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	MR. EDWARD W KALTEN JR.
Credential	:	PT
Telephone Number	:	631-328-5920

Provider Enumeration Date	:	02/03/2009
Last Update Date	:	02/04/2009

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