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General NPI Number Information
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NPI Number | 1861104705
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Entity Type | Organization
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Legal Business Name | SPARK PHYSICAL THERAPY PLLC
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Dates
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Enumeration Date | 12/22/2022
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Last Update Date | 12/22/2022
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Provider Practice Location Address
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Address Line | 1763 DUTCH BROADWAY
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City | ELMONT
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State | NY
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Zip | 11003-5044
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Country | US
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Telephone | 516-812-6145
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Fax | 516-812-6144
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Provider Business Mailing Address
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Address Line | 1763 DUTCH BROADWAY
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City | ELMONT
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State | NY
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Zip | 11003-5044
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Country | US
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Telephone | 516-812-6145
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Fax | 516-812-6144
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Authorized Official
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Title or Position | OWNER
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Name | RANDOLPH D BENDO
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Credential |
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Telephone | 516-812-6145
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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