Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 023135-1 | NY |
NPI | 1134374226 |
---|---|
Provider Name | Mr. Carlos Villaverde Avilla |
First Address | Medford, NY 11763-1583 |
Second Address | Medford, NY 11763-1583 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/11/2008 |
Last Update Date | 18/11/2008 |