Provider Demographics
NPI:1619317815
Name:SOURCE OF PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:SOURCE OF PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARGARITA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUGURUZA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-880-8468
Mailing Address - Street 1:4051 JUNCTION BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-2121
Mailing Address - Country:US
Mailing Address - Phone:718-880-8468
Mailing Address - Fax:
Practice Address - Street 1:4051 JUNCTION BLVD FL 2
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2121
Practice Address - Country:US
Practice Address - Phone:718-880-8468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025885208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03434104Medicaid
NY03434104Medicaid