Provider Demographics
NPI:1578197000
Name:BAYSIDE REHAB PT PC
Entity Type:Organization
Organization Name:BAYSIDE REHAB PT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIEVIC
Authorized Official - Middle Name:BALAAG
Authorized Official - Last Name:EBORA FERNANDO
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:347-777-9707
Mailing Address - Street 1:20801 NORTHERN BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3120
Mailing Address - Country:US
Mailing Address - Phone:347-777-9707
Mailing Address - Fax:332-777-1842
Practice Address - Street 1:20801 NORTHERN BLVD STE 3
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3120
Practice Address - Country:US
Practice Address - Phone:347-777-9707
Practice Address - Fax:332-777-1842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty