Provider Demographics
NPI:1881937423
Name:AVANTGARDE REHABILITATION LIMITED LIABILITY COMPANY
Entity type:Organization
Organization Name:AVANTGARDE REHABILITATION LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIKTORIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOMENKO
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:718-605-1300
Mailing Address - Street 1:8 BUR CT
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-1878
Mailing Address - Country:US
Mailing Address - Phone:732-677-2260
Mailing Address - Fax:
Practice Address - Street 1:520 BLOOMINGDALE RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-2061
Practice Address - Country:US
Practice Address - Phone:718-605-1300
Practice Address - Fax:718-605-8739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-02
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8002032225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty