Provider Demographics
NPI:1730338559
Name:BAY WELLNESS PROGRAM PT, PLLC
Entity type:Organization
Organization Name:BAY WELLNESS PROGRAM PT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:VLADISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-427-4845
Mailing Address - Street 1:2130 85TH ST
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-3212
Mailing Address - Country:US
Mailing Address - Phone:718-427-4845
Mailing Address - Fax:
Practice Address - Street 1:3495 NOSTRAND AVE
Practice Address - Street 2:MAIMONIDES ROOM
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-5131
Practice Address - Country:US
Practice Address - Phone:718-427-4845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022504225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty