Provider Demographics
NPI:1205364239
Name:BAYSIDE ACUPUNCTURE & PHYSICAL THERAPY PLLC
Entity Type:Organization
Organization Name:BAYSIDE ACUPUNCTURE & PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARIEVIC
Authorized Official - Middle Name:BALAAG
Authorized Official - Last Name:EBORA FERNANDO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-224-2250
Mailing Address - Street 1:20801 NORTHERN BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3118
Mailing Address - Country:US
Mailing Address - Phone:718-224-2250
Mailing Address - Fax:917-398-1875
Practice Address - Street 1:20801 NORTHERN BLVD STE 301
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3118
Practice Address - Country:US
Practice Address - Phone:718-224-2250
Practice Address - Fax:917-398-1875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-04
Last Update Date:2022-07-21
Deactivation Date:2018-05-30
Deactivation Code:
Reactivation Date:2018-07-14
Provider Licenses
StateLicense IDTaxonomies
NY005738171100000X
NY034901225100000X
NY027555225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty