Provider Demographics
NPI:1164297974
Name:SPORTS PHYSICAL THERAPY OCCUPATIONA THERAPY AND REHABILITATION SERVIC
Entity Type:Organization
Organization Name:SPORTS PHYSICAL THERAPY OCCUPATIONA THERAPY AND REHABILITATION SERVIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VAKNIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-321-7801
Mailing Address - Street 1:3 HUNTINGTON QUADRANGLE STE 103N
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4601
Mailing Address - Country:US
Mailing Address - Phone:516-474-2816
Mailing Address - Fax:
Practice Address - Street 1:2465 BROADWAY LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-0295
Practice Address - Country:US
Practice Address - Phone:212-877-2525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-21
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty