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General NPI Number Information
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NPI Number | 1710404173
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Entity Type | Organization
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Legal Business Name | 101 AVENUE PHYSICAL THERAPY PC
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Dates
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Enumeration Date | 08/26/2017
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Last Update Date | 08/26/2017
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Provider Practice Location Address
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Address Line | 277 NORTHERN BLVD STE 301
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City | GREAT NECK
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State | NY
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Zip | 11021-4703
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Country | US
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Telephone | 516-472-7861
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Fax |
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Provider Business Mailing Address
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Address Line | 277 NORTHERN BLVD STE 301
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City | GREAT NECK
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State | NY
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Zip | 11021-4703
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | CHANGHUN LEE
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Credential |
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Telephone | 516-472-8761
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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 | 36145
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License Number State | NY
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