MEDICARE: ELITE AQUATIC PHYSICAL THERAPY AND REHABILITATION, P.C.

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	017724	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2517079	OTHER		UNITED HEALTHCARE
2	4473457	OTHER	NY	CIGNA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	P3740765	OTHER		OXFORD
5	0136977	OTHER	NY	GHI
6	03000005	OTHER	NY	HEALTHNET
7	182224	OTHER	NY	ELDERPLAN

General Provider Information

NPI Number	:	1770654568
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE AQUATIC PHYSICAL THERAPY AND REHABILITATION, P.C.

Provider Business Mailing Address
First Line	:	128-130 BRIGHTON BEACH AVENUE
Second Line	:	SUITE 1, 3RD FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11235-8372
Country	:	US
Telephone Number	:	718-996-1854
Fax Number	:	718-996-1694

Provider Business Practice Location Address
First Line	:	128-130 BRIGHTON BEACH AVENUE
Second Line	:	SUITE 1, 3RD FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11235-8372
Country	:	US
Telephone Number	:	718-996-1854
Fax Number	:	718-996-1694

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DANIEL RAY DE GRACIA SINDO
Credential	:	PT, CERT.MDT
Telephone Number	:	718-996-1854

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	03/12/2009

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