Provider Demographics
NPI:1679844302
Name:2012 SMART PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:2012 SMART PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANCISCO
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-669-3828
Mailing Address - Street 1:10119 39TH AVE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-4806
Mailing Address - Country:US
Mailing Address - Phone:347-669-3828
Mailing Address - Fax:347-808-8326
Practice Address - Street 1:10119 39TH AVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-4806
Practice Address - Country:US
Practice Address - Phone:347-669-3828
Practice Address - Fax:347-808-8326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-26
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025085225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY025085-1OtherLICENSE NUMBER
NY02761397Medicaid
NY02761397Medicaid