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NPI Code Detail

MEDICARE: DOMINGO BALTAZAR PTA

MEDICARE: DOMINGO BALTAZAR PTA
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
1225200000XPhysical Therapy Assistant

General Provider Information

NPI Number : 1336437375
Entity Type Code : Individual
Provider Name (Legal Business Name) : DOMINGO BALTAZAR PTA
Provider Business Mailing Address
First Line : 901 S AUSTIN BLVD
Second Line :
City : CHICAGO
State : IL
Zip : 60644-5311
Country : US
Telephone Number : 773-287-9181
Fax Number :
Provider Business Practice Location Address
First Line : 901 S AUSTIN BLVD
Second Line :
City : CHICAGO
State : IL
Zip : 60644-5311
Country : US
Telephone Number : 773-287-9181
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/12/2011
Last Update Date : 07/12/2011

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Directions to “ DOMINGO BALTAZAR PTA” Practice Location

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