Provider Demographics
NPI:1093861163
Name:WESTERN NASSAU PT
Entity Type:Organization
Organization Name:WESTERN NASSAU PT
Other - Org Name:PEAK PERFORMANCE PT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, OCS
Authorized Official - Phone:516-326-4580
Mailing Address - Street 1:1730 LAKEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-2506
Mailing Address - Country:US
Mailing Address - Phone:516-326-4580
Mailing Address - Fax:516-326-0793
Practice Address - Street 1:1730 LAKEVILLE RD
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-2506
Practice Address - Country:US
Practice Address - Phone:516-326-4580
Practice Address - Fax:516-326-0793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ1W9E1Medicare ID - Type UnspecifiedMEDICARE GROUP #