=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215428370
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLYMPUS PT PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2018
-----------------------------------------------------
Last Update Date | 10/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 694 FORT SALONGA RD
-----------------------------------------------------
City | NORTHPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11768-3147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-754-3775
-----------------------------------------------------
Fax | 631-754-3816
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2403 64TH ST APT 1F
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11204-3449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-444-6235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | QUENNIE LADAO-SOTO
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 914-444-6235
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081S0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | 032114
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------