Provider Demographics
NPI:1518522085
Name:LAON PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:LAON PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JEAGWAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:929-600-4257
Mailing Address - Street 1:13620 MAPLE AVE STE 201C
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-5167
Mailing Address - Country:US
Mailing Address - Phone:929-398-3120
Mailing Address - Fax:833-985-0130
Practice Address - Street 1:4199 MAIN ST STE 202B
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5164
Practice Address - Country:US
Practice Address - Phone:929-398-3120
Practice Address - Fax:833-985-0130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-09
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05027858Medicaid