MEDICARE: JOHN WESLY BOWLIN DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2684	NE

General Provider Information

NPI Number	:	1063719144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN WESLY BOWLIN DPT

Provider Business Mailing Address
First Line	:	1463 17TH AVE
Second Line	:
City	:	MITCHELL
State	:	NE
Zip	:	69357-1429
Country	:	US
Telephone Number	:	308-623-1313
Fax Number	:

Provider Business Practice Location Address
First Line	:	1463 17TH AVE
Second Line	:
City	:	MITCHELL
State	:	NE
Zip	:	69357-1429
Country	:	US
Telephone Number	:	308-623-1313
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2011
Last Update Date	:	09/14/2016

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