Provider Demographics
NPI:1922401538
Name:MICHEAL, BAKHOM
Entity Type:Individual
Prefix:
First Name:BAKHOM
Middle Name:
Last Name:MICHEAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:899 BOWLING GREEN DR
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-6103
Mailing Address - Country:US
Mailing Address - Phone:347-656-6998
Mailing Address - Fax:
Practice Address - Street 1:899 BOWLING GREEN DR
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-6103
Practice Address - Country:US
Practice Address - Phone:347-656-6998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-28
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033723225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist