MEDICARE: LATITUDE 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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1326816992
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LATITUDE PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	PO BOX 552
Second Line	:
City	:	SAG HARBOR
State	:	NY
Zip	:	11963-0012
Country	:	US
Telephone Number	:	631-903-7996
Fax Number	:

Provider Business Practice Location Address
First Line	:	34 BAY ST STE 205-206
Second Line	:
City	:	SAG HARBOR
State	:	NY
Zip	:	11963-3104
Country	:	US
Telephone Number	:	631-241-3698
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	GEORGE JAY WILSON
Credential	:
Telephone Number	:	631-919-5189

Provider Enumeration Date	:	12/13/2023
Last Update Date	:	02/09/2024

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Directions to “LATITUDE PHYSICAL THERAPY ” Practice Location

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