Healthcare Provider Details

I. General information

NPI: 1316131303
Provider Name (Legal Business Name): KOAM PHYSICAL THERAPY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2007
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16410 NORTHERN BLVD STE 201
FLUSHING NY
11358-2668
US

IV. Provider business mailing address

16410 NORTHERN BLVD STE 201
FLUSHING NY
11358-2668
US

V. Phone/Fax

Practice location:
  • Phone: 718-463-2700
  • Fax: 718-463-6174
Mailing address:
  • Phone: 718-463-2700
  • Fax: 718-463-6174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number021153
License Number StateNY

VIII. Authorized Official

Name: SOON OK KIM
Title or Position: PRESIDENT
Credential: P.T.
Phone: 718-463-2700