Provider Demographics
NPI:1861985665
Name:INNOVATIVE PHYSICAL THERAPY OF LONG ISLAND P.C.
Entity type:Organization
Organization Name:INNOVATIVE PHYSICAL THERAPY OF LONG ISLAND P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PT
Authorized Official - Prefix:
Authorized Official - First Name:YANIV
Authorized Official - Middle Name:
Authorized Official - Last Name:RAICH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:516-747-2323
Mailing Address - Street 1:193 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-1702
Mailing Address - Country:US
Mailing Address - Phone:516-747-2323
Mailing Address - Fax:516-747-2305
Practice Address - Street 1:193 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-1702
Practice Address - Country:US
Practice Address - Phone:516-747-2323
Practice Address - Fax:516-747-2305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031561261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy