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General NPI Number Information
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NPI Number | 1154678258
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Entity Type | Organization
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Legal Business Name | MITRA PHYSICAL THERAPY
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Dates
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Enumeration Date | 08/07/2012
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Last Update Date | 08/07/2012
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Provider Practice Location Address
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Address Line | 24312 73RD AVE FL 2
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City | DOUGLASTON
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State | NY
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Zip | 11362-2320
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Country | US
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Telephone | 516-451-3427
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Fax | 347-235-0932
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Provider Business Mailing Address
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Address Line | 24312 73RD AVE FL 2
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City | DOUGLASTON
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State | NY
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Zip | 11362-2320
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Country | US
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Telephone | 516-451-3427
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Fax | 347-235-0932
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. THEODERICK I MITRA
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Credential | PT
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Telephone | 516-451-3427
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | 018279
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License Number State | NY
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