Basic Information
| Provider Information | |||||||||
| NPI: | 1508484916 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPORTS PHYSICAL THERAPY OCCUPATIONAL THERAPY AND REHABILITATION SERVIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1983 MARCUS AVE STE 119 | ||||||||
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| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110421016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163217526 | ||||||||
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| Practice Location | |||||||||
| Address1: | 444 MERRICK RD STE 360 | ||||||||
| Address2: | REHAB SUITE 360 | ||||||||
| City: | LYNBROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115632460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165363800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2020 | ||||||||
| LastUpdateDate: | 09/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | VAKNIN | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5163217801 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | 09/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.