1396254249 NPI number — TRIFECTA PHYSICAL THERAPY PC

Table of content: (NPI 1396254249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396254249 NPI number — TRIFECTA PHYSICAL THERAPY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRIFECTA PHYSICAL THERAPY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396254249
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1615 HOBART AVE APT 4A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRONX
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10461-5245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-992-2152
Provider Business Mailing Address Fax Number:
570-729-7242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1070 HAVEMEYER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10462-5310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-992-2152
Provider Business Practice Location Address Fax Number:
570-729-7242
Provider Enumeration Date:
09/22/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SOTELO
Authorized Official First Name:
ROMAN ALLAN
Authorized Official Middle Name:
SAMSON
Authorized Official Title or Position:
PT/OWNER
Authorized Official Telephone Number:
909-992-2152

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  028622 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1396254249 . This is a "NPI TYPE II" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1295059061 . This is a "IND NPI" identifier . This identifiers is of the category "OTHER".




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