=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093469389
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREVAIL PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2022
-----------------------------------------------------
Last Update Date | 02/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2818 DITMARS BLVD
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11105-2716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-515-0680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2818 DITMARS BLVD
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11105-2716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGIONAL BUSINESS MANAGER
-----------------------------------------------------
Name | NICK E HONDROS
-----------------------------------------------------
Credential | PT, MS
-----------------------------------------------------
Telephone | 917-515-0680
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------