Healthcare Provider Details

I. General information

NPI: 1538124011
Provider Name (Legal Business Name): MRS. MARY MEWBORN-BROADUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17900 LINDEN BLVD
JAMAICA NY
11425-0001
US

IV. Provider business mailing address

11456 212TH ST
CAMBRIA HEIGHTS NY
11411-1018
US

V. Phone/Fax

Practice location:
  • Phone: 718-526-1000
  • Fax: 718-298-8531
Mailing address:
  • Phone: 718-526-1000
  • Fax: 718-298-8531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: