=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710585377
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IKPT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2020
-----------------------------------------------------
Last Update Date | 10/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24 W RAILROAD AVE # 308
-----------------------------------------------------
City | TENAFLY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07670-1735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-750-6708
-----------------------------------------------------
Fax | 201-750-6442
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 W RAILROAD AVE # 308
-----------------------------------------------------
City | TENAFLY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07670-1735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-750-6708
-----------------------------------------------------
Fax | 201-750-6442
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ILENA KIPNIS
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 120-175-0670
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------