Provider Demographics
NPI:1225502875
Name:CLASSICAL REHABILITATION PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:CLASSICAL REHABILITATION PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:VLADISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:RAVITSKI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:929-423-7305
Mailing Address - Street 1:415 RARITAN AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-2345
Mailing Address - Country:US
Mailing Address - Phone:718-667-6111
Mailing Address - Fax:
Practice Address - Street 1:501 BRIGHTON BEACH AVE FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6403
Practice Address - Country:US
Practice Address - Phone:929-423-7305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-16
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1922160480OtherNPI INDIVIDUAL