Provider Demographics
NPI:1477819084
Name:FRESH POND PHYSICAL THERAPY ASTORIA, P.C.
Entity Type:Organization
Organization Name:FRESH POND PHYSICAL THERAPY ASTORIA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, PT
Authorized Official - Phone:718-456-2543
Mailing Address - Street 1:6805 FRESH POND RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-5200
Mailing Address - Country:US
Mailing Address - Phone:718-456-2545
Mailing Address - Fax:718-559-6784
Practice Address - Street 1:4618 BROADWAY
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-1628
Practice Address - Country:US
Practice Address - Phone:718-274-4200
Practice Address - Fax:718-559-6784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-09
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015401-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty