Provider Demographics
NPI:1508102849
Name:EXECUTIVE PARK PT OF BRIARCLIFF LLC
Entity Type:Organization
Organization Name:EXECUTIVE PARK PT OF BRIARCLIFF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIELI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-346-5175
Mailing Address - Street 1:1034 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-1328
Mailing Address - Country:US
Mailing Address - Phone:914-509-4640
Mailing Address - Fax:914-509-4639
Practice Address - Street 1:565 N STATE RD
Practice Address - Street 2:
Practice Address - City:BRIARCLIFF
Practice Address - State:NY
Practice Address - Zip Code:10510-1523
Practice Address - Country:US
Practice Address - Phone:914-263-3280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
023806208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty