Provider Demographics
NPI:1053518332
Name:EDGEWATER ORTHOPEDIC PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:EDGEWATER ORTHOPEDIC PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:PELLETIER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:415-425-1524
Mailing Address - Street 1:74 VESPER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:98 CLEARWATER DR
Practice Address - Street 2:SUITE 3
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105
Practice Address - Country:US
Practice Address - Phone:207-781-9885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME3114225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty