Provider Demographics
NPI:1013310481
Name:A LIST PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:A LIST PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AVELINO
Authorized Official - Middle Name:VERGARA
Authorized Official - Last Name:DE CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:646-208-6108
Mailing Address - Street 1:11949 UNION TPKE APT 4C
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-6109
Mailing Address - Country:US
Mailing Address - Phone:646-208-6108
Mailing Address - Fax:646-810-1036
Practice Address - Street 1:11949 UNION TPKE APT 4C
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-6109
Practice Address - Country:US
Practice Address - Phone:646-208-6108
Practice Address - Fax:646-810-1036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency