=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053500827
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BODY REPAIR PHYSICAL THERAPY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2007
-----------------------------------------------------
Last Update Date | 09/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 82-11 37TH AVE
-----------------------------------------------------
City | JACKSON HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11372-7015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-932-1818
-----------------------------------------------------
Fax | 718-932-3222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 82-11 37TH AVE SUITE 602
-----------------------------------------------------
City | JACKSON HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11372-7015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-932-1818
-----------------------------------------------------
Fax | 718-932-3222
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. GLORIA ZAPATA
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 718-932-1818
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 024831
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------