Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 5501007885 | MI |
N | 2251G0304X | Physical Therapist - Geriatrics | 5501007885 | MI |
NPI | 1386786432 |
---|---|
Provider Name | Joseph Donayre Fadullon |
First Address | Bolingbrook, IL 60490-2119 |
Second Address | Bolingbrook, IL 60490-2119 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/02/2007 |
Last Update Date | 20/08/2007 |