Healthcare Provider Details

I. General information

NPI: 1710818182
Provider Name (Legal Business Name): SAMUEL VAZQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 W 93RD ST
NEW YORK NY
10025-7391
US

IV. Provider business mailing address

475 NORTHERN BLVD STE 37
GREAT NECK NY
11021-4802
US

V. Phone/Fax

Practice location:
  • Phone: 212-580-0125
  • Fax: 516-466-7723
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number015364
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: