Basic Information
| Provider Information | |||||||||
| NPI: | 1013022953 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPORTS THERAPY AND REHABILITATION, PTOT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 E 56TH ST | ||||||||
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| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100223609 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 26 FIREMANS MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109703553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453628400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 09/19/2007 | ||||||||
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| AuthorizedOfficialLastName: | FOX | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2123557827 | ||||||||
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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 | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.