Provider Demographics
NPI:1588178297
Name:SHINING STAR PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:SHINING STAR PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:RANADA
Authorized Official - Last Name:LABIAL
Authorized Official - Suffix:
Authorized Official - Credentials:MS PT
Authorized Official - Phone:347-392-8515
Mailing Address - Street 1:18501 HILLSIDE AVE APT 1C
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-4800
Mailing Address - Country:US
Mailing Address - Phone:347-392-8515
Mailing Address - Fax:
Practice Address - Street 1:1700 GREAT NECK RD
Practice Address - Street 2:
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726-2723
Practice Address - Country:US
Practice Address - Phone:631-608-8700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029064-1261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0290641OtherLISCENCE