Provider Demographics
NPI:1740573930
Name:GO PHYSICAL THERAPY AND WELLNESS PC
Entity Type:Organization
Organization Name:GO PHYSICAL THERAPY AND WELLNESS PC
Other - Org Name:DISTINCTIVE HOME PHYSICAL THERAPY, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAGARE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:516-946-6442
Mailing Address - Street 1:5 EDWARDS ST
Mailing Address - Street 2:APT 1G
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-1105
Mailing Address - Country:US
Mailing Address - Phone:516-946-6442
Mailing Address - Fax:
Practice Address - Street 1:5 EDWARDS ST
Practice Address - Street 2:APT 1G
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-1105
Practice Address - Country:US
Practice Address - Phone:516-946-6442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-19
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100050514Medicare PIN