=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831475805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILLENNIUM P.T. AND REHAB. P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2011
-----------------------------------------------------
Last Update Date | 02/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4210 COLDEN ST APT. 209
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11355-4845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-321-8910
-----------------------------------------------------
Fax | 718-321-9022
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4210 COLDEN ST SUITE. 209
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11355-4845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-321-8910
-----------------------------------------------------
Fax | 718-321-9022
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ANDRE DE MONTAGNAC
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 718-321-8910
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 016579-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------