Provider Demographics
NPI:1306498530
Name:KINETIC PT, OT, PLLC
Entity type:Organization
Organization Name:KINETIC PT, OT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEARGIAN
Authorized Official - Middle Name:FORMACION
Authorized Official - Last Name:DECANGCHON
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:347-260-8449
Mailing Address - Street 1:4340 41ST ST
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-3328
Mailing Address - Country:US
Mailing Address - Phone:929-462-0214
Mailing Address - Fax:
Practice Address - Street 1:4340 41ST ST
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-3328
Practice Address - Country:US
Practice Address - Phone:929-462-0214
Practice Address - Fax:929-462-0215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty