Healthcare Provider Details

I. General information

NPI: 1073793378
Provider Name (Legal Business Name): REHABILITATION MEDICINE AND SPORTS SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 MONTAGUE ST SUITE 700
BROOKLYN NY
11201-3610
US

IV. Provider business mailing address

189 MONTAGUE ST SUITE 700
BROOKLYN NY
11201-3610
US

V. Phone/Fax

Practice location:
  • Phone: 718-852-6949
  • Fax: 718-852-7075
Mailing address:
  • Phone: 718-852-6949
  • Fax: 718-852-7075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number183780
License Number StateNY

VIII. Authorized Official

Name: DR. CAROL VR DECOSTA
Title or Position: PRESIDENT
Credential: MD
Phone: 718-852-6949