MEDICARE: OPTIMAL REHABILITATION OT & PT, PLLC

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	174400000X	Specialist	013231	NY
2	174400000X	Specialist	031215	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821461864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMAL REHABILITATION OT & PT, PLLC

Provider Business Mailing Address
First Line	:	721 MELROSE AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10455-1121
Country	:	US
Telephone Number	:	718-554-0064
Fax Number	:	718-544-0221

Provider Business Practice Location Address
First Line	:	721 MELROSE AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10455-1121
Country	:	US
Telephone Number	:	718-554-0064
Fax Number	:	718-554-0221

Authorized Official
Title or Position	:	OWNER
Name	:	MR. IMANUEL FUZAILOV
Credential	:	DPT
Telephone Number	:	917-803-5276

Provider Enumeration Date	:	11/12/2015
Last Update Date	:	08/23/2020

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