Healthcare Provider Details

I. General information

NPI: 1588967475
Provider Name (Legal Business Name): 8TH AVE PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2010
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21915A NORTHERN BLVD
BAYSIDE NY
11361-3525
US

IV. Provider business mailing address

219-15A NORTHERN BLVD
BAYSIDE NY
11361-3525
US

V. Phone/Fax

Practice location:
  • Phone: 718-423-3400
  • Fax: 888-391-2482
Mailing address:
  • Phone: 718-423-3400
  • Fax: 888-391-2482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number023674
License Number StateNY

VIII. Authorized Official

Name: JUNG RYEOL PARK
Title or Position: PRESIDENT
Credential: RPT
Phone: 718-423-3400