=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396382149
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NY OT REHABILITATION SERVICES P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2019
-----------------------------------------------------
Last Update Date | 11/27/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 LENOX AVE APT 2Q
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10026-3822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-741-0252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 LENOX AVE APT 2Q
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10026-3822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-741-0252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAURIS TAVAREZ
-----------------------------------------------------
Credential | OT
-----------------------------------------------------
Telephone | 917-741-0252
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------