=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598749277
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | B.D. MANUAL REHAB PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2005
-----------------------------------------------------
Last Update Date | 06/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3099 CONEY ISLAND AVE 3-RD FLOOR
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235-6305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-739-4583
-----------------------------------------------------
Fax | 718-228-2560
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 166 BEACH 127TH ST
-----------------------------------------------------
City | ROCKAWAY PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11694-1727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-739-4583
-----------------------------------------------------
Fax | 718-228-2560
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | MR. BORIS DOLUB
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 347-739-4583
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 023288
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------