Provider Demographics
NPI:1578837654
Name:DIVINE PADILLA PT PC
Entity Type:Organization
Organization Name:DIVINE PADILLA PT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIVINE
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:PADILLA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-310-0892
Mailing Address - Street 1:1501 IMPERIAL AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-3945
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-3945
Practice Address - Country:US
Practice Address - Phone:718-310-0892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027946252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency