Provider Demographics
NPI:1588010698
Name:JEDIDIAH PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:JEDIDIAH PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOREMARE
Authorized Official - Middle Name:
Authorized Official - Last Name:LADJAHASAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:646-309-8858
Mailing Address - Street 1:3041 BRIGHTON 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-7453
Mailing Address - Country:US
Mailing Address - Phone:718-484-3131
Mailing Address - Fax:347-702-9107
Practice Address - Street 1:3041 BRIGHTON 2ND ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7453
Practice Address - Country:US
Practice Address - Phone:718-484-3131
Practice Address - Fax:347-702-9107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026709225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty