=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932422680
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PLAZA ONE MEDICAL HEALTHCARE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2010
-----------------------------------------------------
Last Update Date | 11/15/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 835 61ST ST 2ND FLOOR
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11220-4312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-854-8869
-----------------------------------------------------
Fax | 718-854-8861
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 894 OAKS DR
-----------------------------------------------------
City | FRANKLIN SQUARE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11010-1936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-270-2755
-----------------------------------------------------
Fax | 516-270-2755
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT- OWNER
-----------------------------------------------------
Name | DR. DANTE ACEBO CUBANGBANG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 718-854-8869
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | 234017
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------