=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548851702
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BACK TO MOVE PT. PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2021
-----------------------------------------------------
Last Update Date | 01/31/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20412 HILLSIDE AVE
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-200-1073
-----------------------------------------------------
Fax | 929-955-9714
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2775 E12TH STREET APT 228
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-300-5184
-----------------------------------------------------
Fax | 929-955-9714
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MOAMEN HASSANEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 646-300-5184
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------