MEDICARE: TRIFECTA 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	028622	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1396254249	OTHER		NPI TYPE II
2	1295059061	OTHER		IND NPI

General Provider Information

NPI Number	:	1396254249
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRIFECTA PHYSICAL THERAPY PC

Provider Business Mailing Address
First Line	:	1615 HOBART AVE APT 4A
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10461-5245
Country	:	US
Telephone Number	:	909-992-2152
Fax Number	:	570-729-7242

Provider Business Practice Location Address
First Line	:	1070 HAVEMEYER AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10462-5310
Country	:	US
Telephone Number	:	909-992-2152
Fax Number	:	570-729-7242

Authorized Official
Title or Position	:	PT/OWNER
Name	:	MR. ROMAN ALLAN SAMSON SOTELO
Credential	:	PT
Telephone Number	:	909-992-2152

Provider Enumeration Date	:	09/22/2017
Last Update Date	:	09/10/2018

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