Provider Demographics
NPI:1417922717
Name:KINGS PARK PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:KINGS PARK PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:631-269-5170
Mailing Address - Street 1:277 INDIAN HEAD ROAD
Mailing Address - Street 2:UNIT A
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-4803
Mailing Address - Country:US
Mailing Address - Phone:631-269-5170
Mailing Address - Fax:631-269-5283
Practice Address - Street 1:277 INDIAN HEAD ROAD
Practice Address - Street 2:UNIT A
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-4803
Practice Address - Country:US
Practice Address - Phone:631-269-5170
Practice Address - Fax:631-269-5283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5555225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ59911Medicare ID - Type Unspecified