Basic Information
| Provider Information | |||||||||
| NPI: | 1033661574 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TEJWANI | ||||||||
| FirstName: | MONA | ||||||||
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| OtherLastName: | BOGHANI | ||||||||
| OtherFirstName: | MONA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 16 MAYBROOK RD | ||||||||
| Address2: | SUITE L | ||||||||
| City: | CAMPBELL HALL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109162743 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 14 THIELLS MOUNT IVY RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | POMONA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109703021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456948808 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2016 | ||||||||
| LastUpdateDate: | 11/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 020821 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.