Healthcare Provider Details

I. General information

NPI: 1235674342
Provider Name (Legal Business Name): 39TH AVENUE PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2016
Last Update Date: 11/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103-18C 39 AVE
CORONA NY
11368
US

IV. Provider business mailing address

103-18C 39AVE
CORONA NY
11368
US

V. Phone/Fax

Practice location:
  • Phone: 718-709-7583
  • Fax: 718-942-9341
Mailing address:
  • Phone: 718-709-7583
  • Fax: 718-942-9341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number028369
License Number StateNY

VIII. Authorized Official

Name: KORINA GALARAGA
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 917-742-0221