Provider Demographics
NPI:1407022817
Name:THERADYNAMICS PHYSICAL REHAB
Entity Type:Organization
Organization Name:THERADYNAMICS PHYSICAL REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OTR/L
Authorized Official - Prefix:
Authorized Official - First Name:GUERLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-548-1212
Mailing Address - Street 1:3871 SEDGWICK AVE
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-4422
Mailing Address - Country:US
Mailing Address - Phone:718-548-1212
Mailing Address - Fax:718-548-1900
Practice Address - Street 1:3871 SEDGWICK AVE
Practice Address - Street 2:SUITE 1B
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-4422
Practice Address - Country:US
Practice Address - Phone:718-548-1212
Practice Address - Fax:718-548-1900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012901302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization