1609288331 NPI number — DYNAMIC PHYSICAL THERAPY OF QUEENS PLLC

Table of content: (NPI 1609288331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609288331 NPI number — DYNAMIC PHYSICAL THERAPY OF QUEENS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DYNAMIC PHYSICAL THERAPY OF QUEENS PLLC
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:
1609288331
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6248 80TH ST FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLE VILLAGE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11379-1323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-429-2888
Provider Business Mailing Address Fax Number:
646-304-8252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5718 WOODSIDE AVE
Provider Second Line Business Practice Location Address:
2FLR SUITE#103
Provider Business Practice Location Address City Name:
WOODSIDE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11377-3415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-205-0030
Provider Business Practice Location Address Fax Number:
646-304-8252
Provider Enumeration Date:
05/29/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BAUTISTA
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
PRACTICE ADMNISTRATOR
Authorized Official Telephone Number:
914-309-9564

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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