Provider Demographics
NPI:1184091068
Name:GJ, PHYSICAL THERAPIST
Entity type:Organization
Organization Name:GJ, PHYSICAL THERAPIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GHOLAMREZA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAHANARA
Authorized Official - Suffix:
Authorized Official - Credentials:DR OF PHYSICAL THERA
Authorized Official - Phone:646-417-1300
Mailing Address - Street 1:18-22 CORPORAL KENNEDY STREET
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360
Mailing Address - Country:US
Mailing Address - Phone:646-417-1300
Mailing Address - Fax:
Practice Address - Street 1:1822 CORPORAL KENNEDY ST
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360-1447
Practice Address - Country:US
Practice Address - Phone:646-417-1300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019910-1252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency