Provider Demographics
NPI:1811276876
Name:BALBOA PT
Entity type:Organization
Organization Name:BALBOA PT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:P
Authorized Official - Last Name:LAMENDOLA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-816-6500
Mailing Address - Street 1:945 HUGUENOT AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-4312
Mailing Address - Country:US
Mailing Address - Phone:718-816-6500
Mailing Address - Fax:718-816-4677
Practice Address - Street 1:945 HUGUENOT AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-4312
Practice Address - Country:US
Practice Address - Phone:718-816-6500
Practice Address - Fax:718-816-4677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-09
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0205341225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ06Q01Medicare UPIN