Healthcare Provider Details

I. General information

NPI: 1578837563
Provider Name (Legal Business Name): GENERATION NEXTWAVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2012
Last Update Date: 03/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 CHURCH RD
GREAT RIVER NY
11739-3023
US

IV. Provider business mailing address

PO BOX 799
GREAT RIVER NY
11739-0799
US

V. Phone/Fax

Practice location:
  • Phone: 631-921-1277
  • Fax: 631-277-0944
Mailing address:
  • Phone: 631-921-1277
  • Fax: 631-277-0944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number018199-1
License Number StateNY

VIII. Authorized Official

Name: KAREN L. CONZO
Title or Position: PHYSICAL THERAPIST
Credential:
Phone: 631-921-1277