Provider Demographics
NPI:1942780317
Name:BORO WELLNESS LLC
Entity Type:Organization
Organization Name:BORO WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:BUENAGUA
Authorized Official - Last Name:RUSTIA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:347-820-1495
Mailing Address - Street 1:4909 FORT HAMILTON PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-3386
Mailing Address - Country:US
Mailing Address - Phone:347-820-1495
Mailing Address - Fax:
Practice Address - Street 1:4909 FORT HAMILTON PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-3386
Practice Address - Country:US
Practice Address - Phone:347-820-1495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022584261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy