Healthcare Provider Details

I. General information

NPI: 1013974476
Provider Name (Legal Business Name): ORTHOPEDIC PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 03/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4128 71ST ST STE CA
WOODSIDE NY
11377
US

IV. Provider business mailing address

4128 71ST ST STE CA
WOODSIDE NY
11377
US

V. Phone/Fax

Practice location:
  • Phone: 718-874-6779
  • Fax: 718-651-6373
Mailing address:
  • Phone: 718-874-6779
  • Fax: 718-651-6373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number0192091
License Number StateNY

VIII. Authorized Official

Name: MR. KEVIN WONG
Title or Position: DIRECTOR
Credential: MSPT OCS
Phone: 718-874-6779