Provider Demographics
NPI:1043698228
Name:RED CORE PT PTA AND REHABILITATION PLLC
Entity Type:Organization
Organization Name:RED CORE PT PTA AND REHABILITATION PLLC
Other - Org Name:REDCORE PHYSICAL THERAPY AND REHABIITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:EDUARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KHO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-509-9888
Mailing Address - Street 1:P.O. BOX 780173
Mailing Address - Street 2:
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378
Mailing Address - Country:US
Mailing Address - Phone:718-509-9888
Mailing Address - Fax:718-509-6144
Practice Address - Street 1:311 ST NICHOLAS AVENUE
Practice Address - Street 2:SUITE E- BASEMENT
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385
Practice Address - Country:US
Practice Address - Phone:718-509-9888
Practice Address - Fax:718-509-6144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-08
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027246-1225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04599515Medicaid