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General NPI Number Information
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NPI Number | 1578197000
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Entity Type | Organization
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Legal Business Name | BAYSIDE REHAB PT PC
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Dates
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Enumeration Date | 02/24/2020
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Last Update Date | 02/24/2020
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Provider Practice Location Address
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Address Line | 20801 NORTHERN BLVD STE 3
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City | BAYSIDE
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State | NY
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Zip | 11361-3120
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Country | US
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Telephone | 347-777-9707
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Fax | 332-777-1842
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Provider Business Mailing Address
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Address Line | 20801 NORTHERN BLVD STE 3
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City | BAYSIDE
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State | NY
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Zip | 11361-3120
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Country | US
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Telephone | 347-777-9707
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Fax | 332-777-1842
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Authorized Official
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Title or Position | MANAGER
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Name | MARIEVIC BALAAG EBORA FERNANDO
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Credential | PT, DPT
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Telephone | 347-777-9707
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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