MEDICARE: BODY HACK HIGH PERFORMANCE 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	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician

General Provider Information

NPI Number	:	1558941328
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BODY HACK HIGH PERFORMANCE PT PLLC

Provider Business Mailing Address
First Line	:	9972 66TH RD APT 1T
Second Line	:
City	:	REGO PARK
State	:	NY
Zip	:	11374-4440
Country	:	US
Telephone Number	:	917-733-3795
Fax Number	:

Provider Business Practice Location Address
First Line	:	1042 JACKSON AVE
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-5819
Country	:	US
Telephone Number	:	718-433-9909
Fax Number	:	718-433-9676

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	MR. CARLOS HUMBERTO ZORRILLA
Credential	:	PT
Telephone Number	:	646-238-3090

Provider Enumeration Date	:	04/14/2021
Last Update Date	:	04/14/2021

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