Provider Demographics
NPI:1396254249
Name:TRIFECTA PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:TRIFECTA PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROMAN ALLAN
Authorized Official - Middle Name:SAMSON
Authorized Official - Last Name:SOTELO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:909-992-2152
Mailing Address - Street 1:1615 HOBART AVE APT 4A
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-5245
Mailing Address - Country:US
Mailing Address - Phone:909-992-2152
Mailing Address - Fax:570-729-7242
Practice Address - Street 1:1070 HAVEMEYER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-5310
Practice Address - Country:US
Practice Address - Phone:909-992-2152
Practice Address - Fax:570-729-7242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-22
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028622225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1396254249OtherNPI TYPE II
1295059061OtherIND NPI