Provider Demographics
NPI:1649392283
Name:EXECUTIVE PARK ORTHOPEDIC & SPORTS PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:EXECUTIVE PARK ORTHOPEDIC & SPORTS PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:914-509-4640
Mailing Address - Street 1:1034 N BROADWAY
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-1328
Mailing Address - Country:US
Mailing Address - Phone:914-509-4640
Mailing Address - Fax:914-509-4639
Practice Address - Street 1:1034 N BROADWAY
Practice Address - Street 2:2ND FLOOR
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1303
Practice Address - Country:US
Practice Address - Phone:914-509-4640
Practice Address - Fax:914-509-4639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0238062251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty