1790837953 NPI number — BODY AND BALANCE PHYSICAL THERAPY,PC

Table of content: (NPI 1790837953)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790837953 NPI number — BODY AND BALANCE PHYSICAL THERAPY,PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BODY AND BALANCE 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:
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:
1790837953
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22415 HORACE HARDING EXPY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND GARDENS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11364-2301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-577-5661
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19413 NORTHERN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLUSHING
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11358-3032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-428-9369
Provider Business Practice Location Address Fax Number:
718-423-9825
Provider Enumeration Date:
01/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NEAMONITIS
Authorized Official First Name:
THEODOSIOS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
718-428-9369

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  62028308 , 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: 62028308 . This is a "LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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