Provider Demographics
NPI:1689979908
Name:ADVANCE AT HOME PHYSICAL THERAPY P.C.
Entity Type:Organization
Organization Name:ADVANCE AT HOME PHYSICAL THERAPY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SAJAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:516-946-8624
Mailing Address - Street 1:39 EAST ST
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1322
Mailing Address - Country:US
Mailing Address - Phone:516-946-8624
Mailing Address - Fax:516-214-6563
Practice Address - Street 1:39 EAST ST
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1322
Practice Address - Country:US
Practice Address - Phone:516-946-8624
Practice Address - Fax:516-214-6563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024884-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty