Provider Demographics
NPI:1639408743
Name:KHANTSIS, ALLA
Entity Type:Individual
Prefix:
First Name:ALLA
Middle Name:
Last Name:KHANTSIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 7TH AVE APT 2A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-3693
Mailing Address - Country:US
Mailing Address - Phone:718-369-8000
Mailing Address - Fax:718-679-9598
Practice Address - Street 1:263 7TH AVE APT 2A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3693
Practice Address - Country:US
Practice Address - Phone:718-369-8000
Practice Address - Fax:718-679-9598
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-18
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0319971261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400026162Medicare PIN