=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154630671
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONNA ELISE SANDOMIR P.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2010
-----------------------------------------------------
Last Update Date | 09/30/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 56 CATHEDRAL AVE
-----------------------------------------------------
City | GARDEN CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11530-2819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-294-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2663 BOUNDARY LN
-----------------------------------------------------
City | BELLMORE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11710-4722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-826-0386
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171W00000X
-----------------------------------------------------
Taxonomy Name | Contractor
-----------------------------------------------------
License Number | 009634-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------