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General NPI Number Information
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NPI Number | 1184091068
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Entity Type | Organization
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Legal Business Name | GJ, PHYSICAL THERAPIST
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Dates
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Enumeration Date | 08/27/2015
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Last Update Date | 08/27/2015
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Provider Practice Location Address
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Address Line | 1822 CORPORAL KENNEDY ST
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City | BAYSIDE
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State | NY
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Zip | 11360-1447
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Country | US
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Telephone | 646-417-1300
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Fax |
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Provider Business Mailing Address
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Address Line | 18-22 CORPORAL KENNEDY STREET
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City | BAYSIDE
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State | NY
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Zip | 11360
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Country | US
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Telephone | 646-417-1300
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GHOLAMREZA JAHANARA
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Credential | DR OF PHYSICAL THERA
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Telephone | 646-417-1300
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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 | 019910-1
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License Number State | NY
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