1568190635 NPI number — LIMITLESS THERAPEUTIC PHYSICAL LLC

Table of content: DR. TUCKER JAMES GENTRY M.D. (NPI 1376534990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568190635 NPI number — LIMITLESS THERAPEUTIC PHYSICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIMITLESS THERAPEUTIC PHYSICAL LLC
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:
6
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:
1568190635
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8413 52ND AVE FL 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELMHURST
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11373-4320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-810-4717
Provider Business Mailing Address Fax Number:
347-727-0505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8413 52ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELMHURST
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11373-4320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-810-4717
Provider Business Practice Location Address Fax Number:
347-727-0505
Provider Enumeration Date:
08/08/2022

Additional Information

Authorized Official

Authorized Official Last Name:
TERRADO
Authorized Official First Name:
MA JHOANNE
Authorized Official Middle Name:
CONCEPCION
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
718-810-4717

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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