Basic Information
| Provider Information | |||||||||
| NPI: | 1205246428 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 576 BROADHOLLOW RD | ||||||||
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| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117475002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182637500 | ||||||||
| FaxNumber: | 7182637502 | ||||||||
| Practice Location | |||||||||
| Address1: | 8002 KEW GARDENS RD | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | KEW GARDENS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114153600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182637500 | ||||||||
| FaxNumber: | 7182637502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2014 | ||||||||
| LastUpdateDate: | 03/29/2018 | ||||||||
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| AuthorizedOfficialLastName: | PABELLON | ||||||||
| AuthorizedOfficialFirstName: | LETICIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF ADMINISTRATIVE OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5163212447 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.