=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437569654
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2014
-----------------------------------------------------
Last Update Date | 03/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 UNION SQ E 3RD FLOOR
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003-3209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-677-3989
-----------------------------------------------------
Fax | 212-677-3994
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 576 BROADHOLLOW RD
-----------------------------------------------------
City | MELVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11747-5002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-677-3989
-----------------------------------------------------
Fax | 212-677-3994
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF ADMINISTRATIVE OPERATIONS
-----------------------------------------------------
Name | LETICIA PABELLON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 516-321-2447
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------