Basic Information
| Provider Information | |||||||||
| NPI: | 1003110164 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ENHANCED PHYSICAL THERAPY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12809 LIBERTY AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH RICHMOND HILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114192217 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 12809 LIBERTY AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH RICHMOND HILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114192217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187437090 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2011 | ||||||||
| LastUpdateDate: | 01/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | KURIAN | ||||||||
| AuthorizedOfficialFirstName: | JACOB | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPY | ||||||||
| AuthorizedOfficialTelephone: | 7187437090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 026465 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.