Provider Demographics
NPI:1710325360
Name:PROFESSIONAL ORTHO & SPORTS PT
Entity Type:Organization
Organization Name:PROFESSIONAL ORTHO & SPORTS PT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:AGRELO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-767-0610
Mailing Address - Street 1:576 BROADHOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-5002
Mailing Address - Country:US
Mailing Address - Phone:718-767-0610
Mailing Address - Fax:
Practice Address - Street 1:2132 MERRICK MALL
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-3626
Practice Address - Country:US
Practice Address - Phone:516-668-8200
Practice Address - Fax:516-668-8208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-05
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ4WFH1Medicare PIN
NY4855530001Medicare NSC