Provider Demographics
NPI:1992102388
Name:BIG STRIDES WIDE REACH OT, PT PLLC
Entity type:Organization
Organization Name:BIG STRIDES WIDE REACH OT, PT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT/MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARMAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORCILLA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-880-1911
Mailing Address - Street 1:11940 METROPOLITAN AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-2600
Mailing Address - Country:US
Mailing Address - Phone:718-880-1911
Mailing Address - Fax:718-487-3425
Practice Address - Street 1:11940 METROPOLITAN AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-2600
Practice Address - Country:US
Practice Address - Phone:718-880-1911
Practice Address - Fax:718-487-3425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center