Provider Demographics
NPI:1003108358
Name:OPTIMAL REHABILITATION OT&PT PLLC
Entity Type:Organization
Organization Name:OPTIMAL REHABILITATION OT&PT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:IMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FUZAILOV
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:917-803-5276
Mailing Address - Street 1:16903 65TH AVE
Mailing Address - Street 2:FLOOR 2
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-1923
Mailing Address - Country:US
Mailing Address - Phone:917-803-5276
Mailing Address - Fax:718-762-1510
Practice Address - Street 1:721 MELROSE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-1121
Practice Address - Country:US
Practice Address - Phone:917-803-5276
Practice Address - Fax:718-762-1510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031215225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty