=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821262809
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRO PERFORMANCE PHYSICAL THERAPY AND WELLNESS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2008
-----------------------------------------------------
Last Update Date | 10/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 70 GLEN ST SUITE 380
-----------------------------------------------------
City | GLEN COVE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11542-2855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-277-1153
-----------------------------------------------------
Fax | 516-277-1154
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 70 GLEN ST SUITE 380
-----------------------------------------------------
City | GLEN COVE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11542-2855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-277-1153
-----------------------------------------------------
Fax | 516-277-1154
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | MR. JONATHAN A VENEGAS
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 516-277-1153
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physical Therapist
-----------------------------------------------------
License Number | 015585-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2251S0007X
-----------------------------------------------------
Taxonomy Name | Sports Physical Therapist
-----------------------------------------------------
License Number | 015585-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 015585-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------