Provider Demographics
NPI:1720526668
Name:THERACORE OT, PC
Entity Type:Organization
Organization Name:THERACORE OT, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BENITO
Authorized Official - Middle Name:A
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:845-480-1760
Mailing Address - Street 1:778 MORRIS PARK AVE # 38
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-3652
Mailing Address - Country:US
Mailing Address - Phone:800-678-8605
Mailing Address - Fax:
Practice Address - Street 1:778 MORRIS PARK AVE # 38
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-3652
Practice Address - Country:US
Practice Address - Phone:800-678-8605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-10
Last Update Date:2018-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011975171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty