MEDICARE: KAREN FAYE CANILLAS 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	225100000X	Physical Therapist	0402841	NY

General Provider Information

NPI Number	:	1306313242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAREN FAYE CANILLAS PT

Provider Business Mailing Address
First Line	:	1620 OHM AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10465-1017
Country	:	US
Telephone Number	:	347-679-0015
Fax Number	:

Provider Business Practice Location Address
First Line	:	787 KING ST
Second Line	:
City	:	PORT CHESTER
State	:	NY
Zip	:	10573-1225
Country	:	US
Telephone Number	:	914-600-7149
Fax Number	:

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

Provider Enumeration Date	:	10/29/2018
Last Update Date	:	10/13/2020

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