Healthcare Provider Details

I. General information

NPI: 1750782256
Provider Name (Legal Business Name): DEER PARK PHYSICAL THERAPY & CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 DEER PARK AVE
DEER PARK NY
11729-1319
US

IV. Provider business mailing address

2103 DEER PARK AVE
DEER PARK NY
11729-1319
US

V. Phone/Fax

Practice location:
  • Phone: 631-242-4500
  • Fax: 631-242-0885
Mailing address:
  • Phone: 631-242-4500
  • Fax: 631-242-0885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number021022-1
License Number StateNY

VIII. Authorized Official

Name: RONALD BREDOW
Title or Position: PHYSICAL THERAPY, OWNER
Credential: MS, PT
Phone: 516-315-2010