MEDICARE: COLLIN CARMILLE BUCOL PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	013581	NY
2	225100000X	Physical Therapist	041343	NY

General Provider Information

NPI Number	:	1275239485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLIN CARMILLE BUCOL PT

Provider Business Mailing Address
First Line	:	38 NEWPORT RD APT 3
Second Line	:
City	:	ISLAND PARK
State	:	NY
Zip	:	11558-1013
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	38 NEWPORT RD APT 3
Second Line	:
City	:	ISLAND PARK
State	:	NY
Zip	:	11558-1013
Country	:	US
Telephone Number	:	646-750-4313
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2023
Last Update Date	:	01/31/2023

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Directions to “ COLLIN CARMILLE BUCOL PT” Practice Location

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