MEDICARE: ECLECTIC PHYSICAL THERAPY LLC

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	261Q00000X	Clinic/Center	005735	CT

General Provider Information

NPI Number	:	1730421397
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ECLECTIC PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	46 DRIFTWOOD LN
Second Line	:
City	:	TRUMBULL
State	:	CT
Zip	:	06611-1861
Country	:	US
Telephone Number	:	203-913-6978
Fax Number	:

Provider Business Practice Location Address
First Line	:	2889 FAIRFIELD AVE
Second Line	:
City	:	BRIDGEPORT
State	:	CT
Zip	:	06605-3211
Country	:	US
Telephone Number	:	203-913-6978
Fax Number	:

Authorized Official
Title or Position	:	PHYSICAL THERAPIST, OWNER
Name	:	JENNIFER LEE IANNUCCI
Credential	:	PT
Telephone Number	:	203-913-6978

Provider Enumeration Date	:	03/21/2013
Last Update Date	:	05/16/2014

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