Healthcare Provider Details

I. General information

NPI: 1003194275
Provider Name (Legal Business Name): CEDAR MOUNTAIN INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2011
Last Update Date: 07/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 5TH AVE RM 309
NEW YORK NY
10016-6695
US

IV. Provider business mailing address

303 5TH AVE RM 309
NEW YORK NY
10016-6695
US

V. Phone/Fax

Practice location:
  • Phone: 347-610-1688
  • Fax:
Mailing address:
  • Phone: 347-610-1688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number004284
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number011620
License Number StateNY

VIII. Authorized Official

Name: ROBERT BENNETT KORODY
Title or Position: PRESIDENT
Credential: M.S. P.T. L.AC.
Phone: 347-610-1688