Provider Demographics
NPI:1740639806
Name:LODES ACUPUNCTURE AND PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:LODES ACUPUNCTURE AND PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-665-8446
Mailing Address - Street 1:6937 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-7265
Mailing Address - Country:US
Mailing Address - Phone:347-665-8446
Mailing Address - Fax:718-381-0700
Practice Address - Street 1:6937 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-7265
Practice Address - Country:US
Practice Address - Phone:347-665-8446
Practice Address - Fax:718-381-0700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0045351261QM1300X
NY0271821261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy