=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679853790
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RED ERICKSON DEYNATA RIDON RPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2011
-----------------------------------------------------
Last Update Date | 08/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 139 FULTON ST RM 502
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10038-2535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-571-2030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 LITCHFIELD AVE
-----------------------------------------------------
City | ELMONT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11003-2717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-734-0336
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 031387-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------