MEDICARE: XPERIENCE PHYSICAL THERAPY, P.C.

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	225100000X	Physical Therapist	031217	NY

General Provider Information

NPI Number	:	1114447752
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	XPERIENCE PHYSICAL THERAPY, P.C.

Provider Business Mailing Address
First Line	:	125 LAKE ST APT 8G-N
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10604-2427
Country	:	US
Telephone Number	:	914-882-0830
Fax Number	:	914-479-0039

Provider Business Practice Location Address
First Line	:	444 S FULTON AVE
Second Line	:	GROUND FLOOR ACTIVE FITNESS
City	:	MOUNT VERNON
State	:	NY
Zip	:	10553-1718
Country	:	US
Telephone Number	:	914-882-0830
Fax Number	:	914-479-0039

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	ROBERT LEMYRE
Credential	:	DPT
Telephone Number	:	914-882-0830

Provider Enumeration Date	:	06/25/2017
Last Update Date	:	06/25/2017

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