Healthcare Provider Details

I. General information

NPI: 1134725369
Provider Name (Legal Business Name): KEHINDE OGUNROTIMI PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2020
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 NORTHERN BLVD STE 11
GREAT NECK NY
11021-4802
US

IV. Provider business mailing address

475 NORTHERN BLVD STE 11
GREAT NECK NY
11021-4802
US

V. Phone/Fax

Practice location:
  • Phone: 516-829-0030
  • Fax: 516-466-7723
Mailing address:
  • Phone: 516-829-0030
  • Fax: 516-466-7723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number046444
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: