Provider Demographics
NPI:1760716047
Name:FUNCTIONAL PHYSICAL THERAPY REHAB PC
Entity Type:Organization
Organization Name:FUNCTIONAL PHYSICAL THERAPY REHAB PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOAQUIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-424-5151
Mailing Address - Street 1:8131 BAXTER AVE
Mailing Address - Street 2:SUITE CD
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1315
Mailing Address - Country:US
Mailing Address - Phone:718-424-5151
Mailing Address - Fax:718-424-9119
Practice Address - Street 1:8131 BAXTER AVE
Practice Address - Street 2:SUITE CD
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1315
Practice Address - Country:US
Practice Address - Phone:718-424-5151
Practice Address - Fax:718-424-9119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-20
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026983-1261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy