Basic Information
| Provider Information | |||||||||
| NPI: | 1689733768 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CPTE - NASHUA INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CPTE - NASHUA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 522 AMHERT STREET STE 22 | ||||||||
| Address2: | CPTE NASHUA INC | ||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030631019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038800448 | ||||||||
| FaxNumber: | 6038815280 | ||||||||
| Practice Location | |||||||||
| Address1: | 522 AMHERT STREET STE 22 | ||||||||
| Address2: | CPTE NASHUA INC | ||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030631019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038800448 | ||||||||
| FaxNumber: | 6038815280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RASTODER | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6038800448 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | NA1182 | 01 | NH | HARVARD PILGRIM | OTHER |