1770654568 NPI number — ELITE AQUATIC PHYSICAL THERAPY AND REHABILITATION, P.C.

Table of content: (NPI 1770654568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770654568 NPI number — ELITE AQUATIC PHYSICAL THERAPY AND REHABILITATION, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELITE AQUATIC PHYSICAL THERAPY AND REHABILITATION, P.C.
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:
1770654568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
128-130 BRIGHTON BEACH AVENUE
Provider Second Line Business Mailing Address:
SUITE 1, 3RD FLOOR
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11235-8372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-996-1854
Provider Business Mailing Address Fax Number:
718-996-1694

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
128-130 BRIGHTON BEACH AVENUE
Provider Second Line Business Practice Location Address:
SUITE 1, 3RD FLOOR
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11235-8372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-996-1854
Provider Business Practice Location Address Fax Number:
718-996-1694
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SINDO
Authorized Official First Name:
DANIEL RAY
Authorized Official Middle Name:
DE GRACIA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
718-996-1854

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  017724 , 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: 2517079 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4473457 . This is a "CIGNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02657674 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P3740765 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0136977 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 03000005 . This is a "HEALTHNET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 182224 . This is a "ELDERPLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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