Healthcare Provider Details

I. General information

NPI: 1750911632
Provider Name (Legal Business Name): REPAIR PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2020
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 EAST 25TH STREET SUITE 1
NEW YORK NY
10010
US

IV. Provider business mailing address

5113 61ST ST
WOODSIDE NY
11377-5831
US

V. Phone/Fax

Practice location:
  • Phone: 347-248-6138
  • Fax:
Mailing address:
  • Phone: 347-248-6138
  • Fax: 212-877-5504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIC CHAN
Title or Position: PRESIDENT/ PHYSICAL THERAPIST
Credential: DPT
Phone: 347-248-6138