Provider Demographics
NPI:1336225572
Name:ADVANCED SPORTS, PHYSICAL & ORTHOPEDIC REHABILITATIVE THERAPY SERVICES
Entity Type:Organization
Organization Name:ADVANCED SPORTS, PHYSICAL & ORTHOPEDIC REHABILITATIVE THERAPY SERVICES
Other - Org Name:ADVANCED S.P.O.R.T.S.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:CAPOBIANCO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-820-9300
Mailing Address - Street 1:17660 UNION TPKE
Mailing Address - Street 2:SUITE 195
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1531
Mailing Address - Country:US
Mailing Address - Phone:718-820-9300
Mailing Address - Fax:718-820-9382
Practice Address - Street 1:17660 UNION TPKE
Practice Address - Street 2:SUITE 195
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366-1531
Practice Address - Country:US
Practice Address - Phone:718-820-9300
Practice Address - Fax:718-820-9382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN82127OtherHEALTHNET
NY05915Medicare ID - Type Unspecified