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Organization
PRIME LEADER PT PC
Active
Organization
PRIME LEADER PT PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
AHMED MOHAMMED MOAMEN GHANEM DPT (OWNER)
(516) 612-7288
Entity
Organization
Contact information
Practice address
139 N CENTRAL AVE, VALLEY STREAM, NY 11580-3856
(516) 612-7288
Mailing address
8535 58TH AVE, ELMHURST, NY 11373-4811
(929) 333-0369
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
35568
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
35568
LICENSE
NY
Enumeration date
02/10/2015
Last updated
02/10/2015
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