Healthcare Provider Details

I. General information

NPI: 1164088712
Provider Name (Legal Business Name): G1L PHYSICAL THERAPY P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2019
Last Update Date: 05/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 WALNUT RD
GLEN COVE NY
11542-2267
US

IV. Provider business mailing address

4630 206TH ST FL 1
BAYSIDE NY
11361-3163
US

V. Phone/Fax

Practice location:
  • Phone: 516-609-9400
  • Fax: 516-609-9402
Mailing address:
  • Phone: 503-901-9772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GIWON LEE
Title or Position: PROVIDER
Credential:
Phone: 503-901-9772