Provider Demographics
NPI:1710179635
Name:LIVICA PHYSICAL THERAPY P.C.
Entity Type:Organization
Organization Name:LIVICA PHYSICAL THERAPY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDGARDO
Authorized Official - Middle Name:MESIAS
Authorized Official - Last Name:LIVICA
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:718-775-6025
Mailing Address - Street 1:1577 LURTING AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-1509
Mailing Address - Country:US
Mailing Address - Phone:718-822-8490
Mailing Address - Fax:
Practice Address - Street 1:2510 WESTCHESTER AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-3512
Practice Address - Country:US
Practice Address - Phone:718-775-6025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015653225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02716585Medicaid
NYP0P015653OtherMETROPLUS
NY0050992OtherTOUCHSTONE
NY0129225OtherGHI
NY2558827OtherUNITED HEALTHCARE
NY02716585Medicaid