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General NPI Number Information
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NPI Number | 1982360038
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Entity Type | Organization
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Legal Business Name | PARK AVENUE PHYSICAL THERAPY PC
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Dates
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Enumeration Date | 11/12/2021
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Last Update Date | 01/06/2024
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Provider Practice Location Address
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Address Line | 207 HALLOCK RD STE 209
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City | STONY BROOK
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State | NY
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Zip | 11790-3082
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Country | US
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Telephone | 631-338-8516
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Fax | 518-984-3120
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Provider Business Mailing Address
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Address Line | 207 HALLOCK RD STE 209
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City | STONY BROOK
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State | NY
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Zip | 11790-3082
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Country | US
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Telephone | 631-338-8516
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Fax | 518-984-3120
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Authorized Official
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Title or Position | OWNER
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Name | JESSIE J KIM
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Credential | PT
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Telephone | 631-338-8516
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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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