MEDICARE: OPTIMAL REHABILITATION OT&PT PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	031215	NY

General Provider Information

NPI Number	:	1003108358
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMAL REHABILITATION OT&PT PLLC

Provider Business Mailing Address
First Line	:	16903 65TH AVE
Second Line	:	FLOOR 2
City	:	FRESH MEADOWS
State	:	NY
Zip	:	11365-1923
Country	:	US
Telephone Number	:	917-803-5276
Fax Number	:	718-762-1510

Provider Business Practice Location Address
First Line	:	721 MELROSE AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10455-1121
Country	:	US
Telephone Number	:	917-803-5276
Fax Number	:	718-762-1510

Authorized Official
Title or Position	:	PT/PHYSICAL THERAPIST
Name	:	MR. IMANUEL FUZAILOV
Credential	:	DPT
Telephone Number	:	917-803-5276

Provider Enumeration Date	:	05/04/2011
Last Update Date	:	05/30/2012

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