=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821480021
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BREAKAWAY PHYSICAL THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2015
-----------------------------------------------------
Last Update Date | 04/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 212 W 91ST ST APT 425
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10024-1333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-484-1410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 W 91ST ST APT 425
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10024-1333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | ALAN SNYDER
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 646-484-1410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 031329-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------