=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992230882
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEDOF3W PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2017
-----------------------------------------------------
Last Update Date | 04/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 424 W 110TH ST APT 15A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10025-2408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-774-9997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 424 W 110TH ST APT 15A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10025-2408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-774-9997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. DANIEL ROTH
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 917-774-9997
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 0287971
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------