MEDICARE: AQUA HEALTH PHYSICAL THERAPY PC

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

General Provider Information

NPI Number	:	1326060567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AQUA HEALTH PHYSICAL THERAPY PC

Provider Business Mailing Address
First Line	:	1523 VOORHIES AVE FL 1
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3912
Country	:	US
Telephone Number	:	718-769-8400
Fax Number	:	718-769-3255

Provider Business Practice Location Address
First Line	:	2753 CONEY ISLAND AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-5015
Country	:	US
Telephone Number	:	718-769-8400
Fax Number	:	718-769-3255

Authorized Official
Title or Position	:	PRESIDENT
Name	:	VITALIY GONIKMAN
Credential	:	DPT
Telephone Number	:	718-687-8027

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	06/21/2021

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