Provider Demographics
NPI:1982360038
Name:PARK AVENUE PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:PARK AVENUE PHYSICAL THERAPY PC
Other - Org Name:BROOK PHYSICAL THERAPY PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:631-338-8516
Mailing Address - Street 1:207 HALLOCK RD STE 209
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3082
Mailing Address - Country:US
Mailing Address - Phone:631-338-8516
Mailing Address - Fax:518-984-3120
Practice Address - Street 1:207 HALLOCK RD STE 209
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3082
Practice Address - Country:US
Practice Address - Phone:631-338-8516
Practice Address - Fax:518-984-3120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-12
Last Update Date:2024-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty