Healthcare Provider Details

I. General information

NPI: 1265661524
Provider Name (Legal Business Name): GROWTH WITH PHYSICAL THERAPY P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 07/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2307 AVENUE O
BROOKLYN NY
11210-5132
US

IV. Provider business mailing address

2307 AVENUE O
BROOKLYN NY
11210-5132
US

V. Phone/Fax

Practice location:
  • Phone: 718-496-7795
  • Fax:
Mailing address:
  • Phone: 718-496-7795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number029980
License Number StateNY

VIII. Authorized Official

Name: YISROEL PUPKO
Title or Position: SOLE PROPRIETOR
Credential: P.T.
Phone: 718-496-7795