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General NPI Number Information
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NPI Number | 1770363400
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Entity Type | Organization
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Legal Business Name | PHYSIO REHAB PT PC
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Dates
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Enumeration Date | 10/02/2023
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Last Update Date | 10/02/2023
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Provider Practice Location Address
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Address Line | 14843 HILLSIDE AVE
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City | JAMAICA
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State | NY
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Zip | 11435-3330
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Country | US
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Telephone | 646-384-3095
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Fax |
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Provider Business Mailing Address
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Address Line | 165 WESTWOOD DR APT 180
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City | WESTBURY
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State | NY
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Zip | 11590-1628
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Country | US
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Telephone | 646-384-3095
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MENNATALLAH IBRAHIM
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Credential |
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Telephone | 646-384-3095
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number |
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License Number State |
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