Provider Demographics
NPI:1285851196
Name:BALLESTEROS, ROMMEL O R (PT)
Entity Type:Individual
Prefix:MR
First Name:ROMMEL
Middle Name:O R
Last Name:BALLESTEROS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 AVISTON STREET
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306
Mailing Address - Country:US
Mailing Address - Phone:917-257-0927
Mailing Address - Fax:718-979-7005
Practice Address - Street 1:128 AVISTON STREET
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-5323
Practice Address - Country:US
Practice Address - Phone:917-257-0927
Practice Address - Fax:718-979-7005
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020092-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist