Provider Demographics
NPI:1780202192
Name:SPORTS PHYSICAL THERAPY OCCUPATIONAL THERAPY AND REHABILITATION SERVIC
Entity Type:Organization
Organization Name:SPORTS PHYSICAL THERAPY OCCUPATIONAL THERAPY AND REHABILITATION SERVIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VAKNIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:516-321-7801
Mailing Address - Street 1:3 HUNTINGTON QUADRANGLE STE 103N
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4601
Mailing Address - Country:US
Mailing Address - Phone:516-474-2816
Mailing Address - Fax:
Practice Address - Street 1:3311 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-3611
Practice Address - Country:US
Practice Address - Phone:718-448-3210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-12
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Single Specialty