Provider Demographics
NPI:1790798890
Name:NANDA J NEVOLA PT PC
Entity Type:Organization
Organization Name:NANDA J NEVOLA PT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:NANDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:NEVOLA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:453-002-8478
Mailing Address - Street 1:104 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY COTTAGE
Mailing Address - State:NY
Mailing Address - Zip Code:10989-2339
Mailing Address - Country:US
Mailing Address - Phone:845-300-2847
Mailing Address - Fax:866-841-2452
Practice Address - Street 1:104 LAKE RD
Practice Address - Street 2:
Practice Address - City:VALLEY COTTAGE
Practice Address - State:NY
Practice Address - Zip Code:10989-2339
Practice Address - Country:US
Practice Address - Phone:845-300-2847
Practice Address - Fax:866-841-2452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015158225100000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNN0Q8W0H10OtherBLUE CROSS BLUE SHIELD
NYQ8W0H1Medicare ID - Type UnspecifiedCORP MEDICARE PROVIDER ID