Provider Demographics
NPI:1821125147
Name:PROACTIVE PHYSICAL THERAPY & SPORTS REHABILITATION, PLLC
Entity Type:Organization
Organization Name:PROACTIVE PHYSICAL THERAPY & SPORTS REHABILITATION, PLLC
Other - Org Name:PROACTIVE PHYSICAL THERAPY & SPORTS REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEMETRIOS
Authorized Official - Middle Name:
Authorized Official - Last Name:FARMAKOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT OCS
Authorized Official - Phone:914-741-2850
Mailing Address - Street 1:465 COLUMBUS AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:VALHALLA
Mailing Address - State:NY
Mailing Address - Zip Code:10595-1336
Mailing Address - Country:US
Mailing Address - Phone:914-741-2850
Mailing Address - Fax:914-741-2851
Practice Address - Street 1:465 COLUMBUS AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-1336
Practice Address - Country:US
Practice Address - Phone:914-741-2850
Practice Address - Fax:914-741-2851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ4WBF1Medicare PIN