Provider Demographics
NPI:1366681330
Name:PRO-HEALTH MEDICAL P.C.
Entity type:Organization
Organization Name:PRO-HEALTH MEDICAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:JIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-577-8863
Mailing Address - Street 1:4265 KISSENA BLVD #517
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355
Mailing Address - Country:US
Mailing Address - Phone:718-577-8863
Mailing Address - Fax:718-358-2806
Practice Address - Street 1:4265 KISSENA BLVD #517
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355
Practice Address - Country:US
Practice Address - Phone:718-577-8863
Practice Address - Fax:718-358-2806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-13
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003201171100000X
NY241419225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty