Provider Demographics
NPI:1508099417
Name:DEKHTYAREV PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:DEKHTYAREV PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEKSANDR
Authorized Official - Middle Name:
Authorized Official - Last Name:DEKHTYAREV
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:1917-538-5175
Mailing Address - Street 1:2044 E 18TH ST APT 2F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-3836
Mailing Address - Country:US
Mailing Address - Phone:917-538-5175
Mailing Address - Fax:
Practice Address - Street 1:1811 QUENTIN RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1343
Practice Address - Country:US
Practice Address - Phone:917-538-5175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-26
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030526320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities