Provider Demographics
NPI:1568853786
Name:PRIME LEADER PT PC
Entity Type:Organization
Organization Name:PRIME LEADER PT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AHMED
Authorized Official - Middle Name:MOHAMMED MOAMEN
Authorized Official - Last Name:GHANEM
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:516-612-7288
Mailing Address - Street 1:8535 58TH AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4811
Mailing Address - Country:US
Mailing Address - Phone:929-333-0369
Mailing Address - Fax:
Practice Address - Street 1:139 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-3856
Practice Address - Country:US
Practice Address - Phone:516-612-7288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY35568225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY35568OtherLICENSE