Provider Demographics
NPI:1487717500
Name:ULTIMATE PHYSICAL THERAPY
Entity type:Organization
Organization Name:ULTIMATE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MASSAGE THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:914-328-3750
Mailing Address - Street 1:25 W RED OAK LN
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10604-3601
Mailing Address - Country:US
Mailing Address - Phone:914-328-3750
Mailing Address - Fax:914-328-6945
Practice Address - Street 1:25 W RED OAK LN
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10604-3601
Practice Address - Country:US
Practice Address - Phone:914-328-3750
Practice Address - Fax:914-328-6945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0188881225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty