Provider Demographics
NPI:1578837563
Name:GENERATION NEXTWAVE
Entity Type:Organization
Organization Name:GENERATION NEXTWAVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:L
Authorized Official - Last Name:CONZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-921-1277
Mailing Address - Street 1:PO BOX 799
Mailing Address - Street 2:
Mailing Address - City:GREAT RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11739-0799
Mailing Address - Country:US
Mailing Address - Phone:631-921-1277
Mailing Address - Fax:631-277-0944
Practice Address - Street 1:41 CHURCH RD
Practice Address - Street 2:
Practice Address - City:GREAT RIVER
Practice Address - State:NY
Practice Address - Zip Code:11739-3023
Practice Address - Country:US
Practice Address - Phone:631-921-1277
Practice Address - Fax:631-277-0944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018199-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ34Z3Q76U1Medicare PIN