Basic Information
| Provider Information | |||||||||
| NPI: | 1710325360 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL ORTHO & SPORTS PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 576 BROADHOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117475002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187670610 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2132 MERRICK MALL | ||||||||
| Address2: | |||||||||
| City: | MERRICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115663626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166688200 | ||||||||
| FaxNumber: | 5166688208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2013 | ||||||||
| LastUpdateDate: | 03/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | AGRELO | ||||||||
| AuthorizedOfficialFirstName: | HELEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | REGIONAL BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7187670610 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.