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General NPI Number Information
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NPI Number | 1205364239
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Entity Type | Organization
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Legal Business Name | BAYSIDE ACUPUNCTURE & PHYSICAL THERAPY PLLC
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Dates
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Enumeration Date | 06/04/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 20801 NORTHERN BLVD STE 301
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City | BAYSIDE
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State | NY
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Zip | 11361-3118
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Country | US
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Telephone | 718-224-2250
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Fax | 917-398-1875
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Provider Business Mailing Address
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Address Line | 20801 NORTHERN BLVD STE 301
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City | BAYSIDE
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State | NY
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Zip | 11361-3118
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Country | US
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Telephone | 718-224-2250
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Fax | 917-398-1875
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MARIEVIC BALAAG EBORA FERNANDO
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Credential | PT
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Telephone | 718-224-2250
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 005738
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 027555
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License Number State | NY
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Taxonomy #3
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 034901
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License Number State | NY
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