Provider Demographics
NPI:1821262809
Name:PRO PERFORMANCE PHYSICAL THERAPY AND WELLNESS, PLLC
Entity Type:Organization
Organization Name:PRO PERFORMANCE PHYSICAL THERAPY AND WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:VENEGAS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:516-277-1153
Mailing Address - Street 1:70 GLEN ST
Mailing Address - Street 2:SUITE 380
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2855
Mailing Address - Country:US
Mailing Address - Phone:516-277-1153
Mailing Address - Fax:516-277-1154
Practice Address - Street 1:70 GLEN ST
Practice Address - Street 2:SUITE 380
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2855
Practice Address - Country:US
Practice Address - Phone:516-277-1153
Practice Address - Fax:516-277-1154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-21
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015585-12251N0400X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurologyGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100000028Medicare PIN