Provider Demographics
NPI:1073717542
Name:REVERB PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:REVERB PHYSICAL THERAPY PC
Other - Org Name:REVERB PT PC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNEDY
Authorized Official - Middle Name:NAGUIT
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-805-6537
Mailing Address - Street 1:9049 SILVER RD
Mailing Address - Street 2:
Mailing Address - City:OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11417-2050
Mailing Address - Country:US
Mailing Address - Phone:718-805-6537
Mailing Address - Fax:
Practice Address - Street 1:17013 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-4546
Practice Address - Country:US
Practice Address - Phone:718-805-6537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023615225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty