Provider Demographics
NPI:1316222474
Name:MAMARONECK PHYSICAL THERAPY P.C.
Entity Type:Organization
Organization Name:MAMARONECK PHYSICAL THERAPY P.C.
Other - Org Name:PHYSICAL THERAPY ASSOCIATE OF QUEENS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-606-0849
Mailing Address - Street 1:8202 GRAND AVE
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4133
Mailing Address - Country:US
Mailing Address - Phone:718-606-0849
Mailing Address - Fax:718-606-1077
Practice Address - Street 1:8202 GRAND AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-4133
Practice Address - Country:US
Practice Address - Phone:718-606-0849
Practice Address - Fax:718-606-1077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032724225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty