Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics | 40QA01009100 | NJ |
NPI | 1194911933 |
---|---|
Provider Name | Mr. Wirt Rainier Villanueva |
First Address | Manchester, NJ 08759-5918 |
Second Address | Brick, NJ 08723-7800 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/09/2007 |
Last Update Date | 14/09/2007 |