MEDICARE: MR. VICTOR MICHAEL SACKETT III PT

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	014736-1	NY

General Provider Information

NPI Number	:	1982608766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VICTOR MICHAEL SACKETT III PT

Provider Business Mailing Address
First Line	:	14 COSGROVE DR
Second Line	:
City	:	GLEN COVE
State	:	NY
Zip	:	11542-2601
Country	:	US
Telephone Number	:	516-695-4998
Fax Number	:	516-403-1862

Provider Business Practice Location Address
First Line	:	14 COSGROVE DR
Second Line	:
City	:	GLEN COVE
State	:	NY
Zip	:	11542-2601
Country	:	US
Telephone Number	:	516-695-4998
Fax Number	:	516-403-1862

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	07/09/2007

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