=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861306490
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROY I BALACANAO JR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2026
-----------------------------------------------------
Last Update Date | 09/30/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3164 21ST ST
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11106-4573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-648-0888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1566 HILLSIDE AVE
-----------------------------------------------------
City | NEW HYDE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11040-2527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-932-8494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 056271
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------