Healthcare Provider Details

I. General information

NPI: 1336971266
Provider Name (Legal Business Name): SHARE A SMILE PHYSICAL THERPAY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 08/19/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39-07 PRINCE ST 5A
FLUSHING NY
11354-5357
US

IV. Provider business mailing address

524 JERUSALEM AVE
HICKSVILLE NY
11801-5526
US

V. Phone/Fax

Practice location:
  • Phone: 929-422-3880
  • Fax: 718-732-1307
Mailing address:
  • Phone: 929-422-3880
  • Fax: 718-732-1307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251E1300X
TaxonomyClinical Electrophysiology Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: ANOOP CHACKO
Title or Position: OWNER
Credential: PT
Phone: 718-707-6970