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General NPI Number Information
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NPI Number | 1184916124
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Entity Type | Organization
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Legal Business Name | ROYAL REHAB PHYSICAL THERAPY PC
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Dates
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Enumeration Date | 05/10/2011
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Last Update Date | 05/10/2011
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Provider Practice Location Address
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Address Line | 92-56 QUEENS BLVD
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City | REGO PARK
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State | NY
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Zip | 11374
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Country | US
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Telephone | 718-426-5100
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Fax | 718-426-5110
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Provider Business Mailing Address
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Address Line | 9735 63 RD DR
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City | REGO PARK
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State | NY
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Zip | 11374
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Country | US
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Telephone | 718-426-5100
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Fax | 718-426-5110
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Authorized Official
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Title or Position | P.T.
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Name | YAN YUSUPOV
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Credential | P.T.
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Telephone | 718-426-5100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 031272
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License Number State | NY
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