Healthcare Provider Details

I. General information

NPI: 1952406985
Provider Name (Legal Business Name): PAIN AND REHABILITATION MEDICAL SPECIALISTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 GUY LOMBARDO AVE
FREEPORT NY
11520-3714
US

IV. Provider business mailing address

73 GUY LOMBARDO AVE
FREEPORT NY
11520-3714
US

V. Phone/Fax

Practice location:
  • Phone: 516-377-3332
  • Fax: 516-377-3844
Mailing address:
  • Phone: 516-377-3332
  • Fax: 516-377-3844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number221976
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number244683
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number026755
License Number StateNY

VIII. Authorized Official

Name: JUAN LEDON
Title or Position: PRESIDENT
Credential: MD
Phone: 516-377-3332