Healthcare Provider Details

I. General information

NPI: 1922163468
Provider Name (Legal Business Name): PROMEDEX. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136-71 41AVE
FLUSHING NY
11355-2433
US

IV. Provider business mailing address

136-71 41AVE
FLUSHING NY
11355-2433
US

V. Phone/Fax

Practice location:
  • Phone: 718-939-4008
  • Fax: 718-939-5508
Mailing address:
  • Phone: 718-939-4008
  • Fax: 718-939-5508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224L00000X
TaxonomyPedorthist
License NumberC49901
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberC0002130
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateNY

VIII. Authorized Official

Name: MR. JONG KU PARK
Title or Position: PRESIDENT
Credential:
Phone: 718-939-4008