Healthcare Provider Details

I. General information

NPI: 1962366591
Provider Name (Legal Business Name): NICHOLAS PELLEGRINO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 LAKEVILLE RD
NEW HYDE PARK NY
11040-2506
US

IV. Provider business mailing address

57 5TH AVE
GARDEN CITY PARK NY
11040-5003
US

V. Phone/Fax

Practice location:
  • Phone: 516-326-4580
  • Fax:
Mailing address:
  • Phone: 516-852-1464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number054945-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: