Provider Demographics
NPI:1659549715
Name:TLC CLOVE LAKE PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:TLC CLOVE LAKE PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TOA
Authorized Official - Middle Name:CHRIS
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-238-9392
Mailing Address - Street 1:1428 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3908
Mailing Address - Country:US
Mailing Address - Phone:718-698-3055
Mailing Address - Fax:718-448-1875
Practice Address - Street 1:1428 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3908
Practice Address - Country:US
Practice Address - Phone:718-698-3055
Practice Address - Fax:718-448-1875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty