=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376354787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRANDON PARK PHYSICAL THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2025
-----------------------------------------------------
Last Update Date | 02/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 233 BROADWAY RM 1775
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10279-1810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-921-7900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 275 BROADWAY APT 2F
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11211-8410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-846-0815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | BRANDON PARK
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 470-846-0815
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------