MEDICARE: BLACK ROCK PHYSICAL THERAPY

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	261QP2000X	Physical Therapy Clinic/Center	004078	CT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D100000150	OTHER	CT	MEDICARE PTAN

General Provider Information

NPI Number	:	1063650901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK ROCK PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	2889 FAIRFIELD AVE
Second Line	:
City	:	BRIDGEPORT
State	:	CT
Zip	:	06605-3211
Country	:	US
Telephone Number	:	203-335-1987
Fax Number	:	203-549-0725

Provider Business Practice Location Address
First Line	:	2889 FAIRFIELD AVE
Second Line	:
City	:	BRIDGEPORT
State	:	CT
Zip	:	06605-3211
Country	:	US
Telephone Number	:	203-335-1987
Fax Number	:	203-549-0725

Authorized Official
Title or Position	:	PHYSICAL THERAPIST/OWNER
Name	:	MS. TARA LYNN COLLINS
Credential	:	P.T., IMT.C., CSCS
Telephone Number	:	203-345-1720

Provider Enumeration Date	:	01/30/2009
Last Update Date	:	05/03/2018

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Directions to “BLACK ROCK PHYSICAL THERAPY ” Practice Location

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