Healthcare Provider Details

I. General information

NPI: 1316375892
Provider Name (Legal Business Name): TATAY NINONG PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2013
Last Update Date: 05/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7909B NORTHERN BLVD
JACKSON HEIGHTS NY
11372-1223
US

IV. Provider business mailing address

3344 105TH ST APT 3
CORONA NY
11368-1121
US

V. Phone/Fax

Practice location:
  • Phone: 718-507-1438
  • Fax: 718-507-1530
Mailing address:
  • Phone: 347-605-7946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number029005
License Number StateNY

VIII. Authorized Official

Name: MR. MICHAEL KRISTIAN MANGUBAT
Title or Position: MANAGER/OWNER
Credential: RPT
Phone: 347-605-7946