Healthcare Provider Details

I. General information

NPI: 1558409110
Provider Name (Legal Business Name): BIENVENIDO PONCARDAS CEBALLOS JR. BSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 POST AVE STE 205
WESTBURY NY
11590-4361
US

IV. Provider business mailing address

15 MONMOUTH ST
DEER PARK NY
11729-2514
US

V. Phone/Fax

Practice location:
  • Phone: 516-338-0412
  • Fax: 516-338-1106
Mailing address:
  • Phone: 631-839-4061
  • Fax: 631-274-5940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number019520
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: