Provider Demographics
NPI:1821461864
Name:OPTIMAL REHABILITATION OT & PT, PLLC
Entity Type:Organization
Organization Name:OPTIMAL REHABILITATION OT & PT, PLLC
Other - Org Name:OPTIMAL REHABILITATION OT & PT, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:IMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FUZAILOV
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:917-803-5276
Mailing Address - Street 1:721 MELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-1121
Mailing Address - Country:US
Mailing Address - Phone:718-554-0064
Mailing Address - Fax:718-544-0221
Practice Address - Street 1:721 MELROSE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-1121
Practice Address - Country:US
Practice Address - Phone:718-554-0064
Practice Address - Fax:718-554-0221
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OPTIMAL REHABILITATION OT & PT, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-12
Last Update Date:2020-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031215174400000X
NY013231174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03381106Medicaid
NYA100054752Medicare PIN