Provider Demographics
NPI:1730503178
Name:IMPERIAL REHAB PT PC
Entity type:Organization
Organization Name:IMPERIAL REHAB PT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KHALED
Authorized Official - Middle Name:
Authorized Official - Last Name:AAGA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:631-805-8655
Mailing Address - Street 1:30 BAY 17TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-3706
Mailing Address - Country:US
Mailing Address - Phone:631-805-8655
Mailing Address - Fax:
Practice Address - Street 1:21808 HEMPSTEAD AVE
Practice Address - Street 2:2 FL
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-1235
Practice Address - Country:US
Practice Address - Phone:631-805-8655
Practice Address - Fax:718-998-9059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032839225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY032839OtherLICENSE