=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437538915
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRONX PHYSICAL THERAPY AND REHABILITATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2015
-----------------------------------------------------
Last Update Date | 05/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 984 MORRIS PARK AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10462-3714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-823-7676
-----------------------------------------------------
Fax | 718-823-7675
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1418 ROUTE 300
-----------------------------------------------------
City | NEWBURGH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12550-2992
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-566-4202
-----------------------------------------------------
Fax | 845-566-4238
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PT
-----------------------------------------------------
Name | MR. SAMUEL IGNACIO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 914-843-8224
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 011191
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------