Healthcare Provider Details

I. General information

NPI: 1245855519
Provider Name (Legal Business Name): LIFELONG REHAB ENTERPRISES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 06/12/2020
Certification Date: 06/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 CHARDONNAY DR
EAST QUOGUE NY
11942-3829
US

IV. Provider business mailing address

143 CHARDONNAY DR
EAST QUOGUE NY
11942-3829
US

V. Phone/Fax

Practice location:
  • Phone: 631-278-0665
  • Fax: 631-532-4886
Mailing address:
  • Phone: 631-278-0665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFREY CIOLINO
Title or Position: PRESIDENT
Credential: OTR
Phone: 631-278-0665