Provider Demographics
NPI:1225303241
Name:SAMALEA, RENEN BERMUDO
Entity Type:Individual
Prefix:MR
First Name:RENEN
Middle Name:BERMUDO
Last Name:SAMALEA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 TINTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-3218
Mailing Address - Country:US
Mailing Address - Phone:718-292-5478
Mailing Address - Fax:718-292-5476
Practice Address - Street 1:628 TINTON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-3218
Practice Address - Country:US
Practice Address - Phone:718-292-5478
Practice Address - Fax:718-292-5476
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029756225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist