Provider Demographics
NPI:1093141533
Name:STANLEY PARK PHYSICAL THERAPY, P.C.
Entity Type:Organization
Organization Name:STANLEY PARK PHYSICAL THERAPY, P.C.
Other - Org Name:BELL PHYSICAL THERAPY & REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SEJOONG
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:718-423-5100
Mailing Address - Street 1:4711 BELL BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3333
Mailing Address - Country:US
Mailing Address - Phone:718-423-5100
Mailing Address - Fax:
Practice Address - Street 1:4711 BELL BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3333
Practice Address - Country:US
Practice Address - Phone:718-423-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-16
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04029030Medicaid
NY04029030Medicaid