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General NPI Number Information
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NPI Number | 1740621697
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Entity Type | Organization
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Legal Business Name | PRO FORM PHYSICAL THERAPY PC
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Dates
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Enumeration Date | 07/08/2013
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Last Update Date | 03/01/2016
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Provider Practice Location Address
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Address Line | 1973 UNIVERSITY AVE
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City | BRONX
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State | NY
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Zip | 10453-4404
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Country | US
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Telephone | 718-618-0052
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Fax | 718-534-4135
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Provider Business Mailing Address
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Address Line | 95-22 63RD ROAD SUITE 412
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City | REGO PARK
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State | NY
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Zip | 11374-1142
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Country | US
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Telephone | 718-618-0052
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Fax | 718-534-4135
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Authorized Official
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Title or Position | OWNER/PHYSICAL THERAPIST
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Name | SAM HANNA
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Credential | PT
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Telephone | 917-545-9249
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 021421
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 025663
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License Number State | NY
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