=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184088577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REHABWISE PHYSICAL THERAPY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2016
-----------------------------------------------------
Last Update Date | 04/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 347 E 14TH ST APT 4R
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003-4234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-669-8104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 372
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10009-0372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-669-8104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. MICHAEL OLARIO GALLANO
-----------------------------------------------------
Credential | PT, DPT, PCS, CSCS
-----------------------------------------------------
Telephone | 917-669-8104
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 024305-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------