| Organization Name: | NICOLE DERUE PHYSICAL THERAPY P.C. |
| NPI Number: | 1053503185 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | NICOLE BLYTHE DERUE (PRESIDENT) |
| Mailing Address: | 573 S Main St Central Square |
| State: | NY US |
| Postal Code: | 130369785 |
| Phone Number: | 3156763826 |
| Fax Number: | 3156763402 |
| NPI Enumeration Date: | 08/13/2007 |
| NPI Last Update Date: | 11/21/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2000X |
| License Number: | 0590998 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Physical Therapy |
| Taxonomy Definition: | |