Provider Demographics
NPI:1114275682
Name:PRIME PHYSIQUE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PRIME PHYSIQUE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT; DOCTOR OF PT
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:THERNELAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:917-805-7031
Mailing Address - Street 1:229 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-1708
Mailing Address - Country:US
Mailing Address - Phone:917-805-7031
Mailing Address - Fax:718-679-9214
Practice Address - Street 1:229 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-1708
Practice Address - Country:US
Practice Address - Phone:917-805-7031
Practice Address - Fax:718-679-9214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030276225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300065714Medicare UPIN