MEDICARE: NUNDA PHYSICAL THERAPY 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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1255952099
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NUNDA PHYSICAL THERAPY PLLC

Provider Business Mailing Address
First Line	:	25 S WEST ST PO BOX 614
Second Line	:
City	:	NUNDA
State	:	NY
Zip	:	14517-9685
Country	:	US
Telephone Number	:	585-468-2020
Fax Number	:	585-468-5001

Provider Business Practice Location Address
First Line	:	25 S WEST ST
Second Line	:
City	:	NUNDA
State	:	NY
Zip	:	14517-9685
Country	:	US
Telephone Number	:	585-468-2020
Fax Number	:	585-468-5001

Authorized Official
Title or Position	:	PT/OWNER/AUTHORIZED OFFICIAL
Name	:	MRS. ALICIA ANN EBERSOLE
Credential	:	PT
Telephone Number	:	585-468-2020

Provider Enumeration Date	:	05/04/2020
Last Update Date	:	05/04/2020

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