Healthcare Provider Details

I. General information

NPI: 1942653563
Provider Name (Legal Business Name): SPORTS PHYSICAL THERAPY OCCUPATIONAL THERAPY AND REHABILITATION SERVIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 NORTHERN BLVD STE 235
GREAT NECK NY
11021-5339
US

IV. Provider business mailing address

3 HUNTINGTON QUADRANGLE STE 103N
MELVILLE NY
11747-4601
US

V. Phone/Fax

Practice location:
  • Phone: 516-288-3400
  • Fax:
Mailing address:
  • Phone: 516-474-2816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251H1200X
TaxonomyHand Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: DANIEL VAKNIN
Title or Position: VICE PRESIDENT
Credential: PT
Phone: 516-321-7801