MEDICARE: NICOLE CARBAJAL P.T.

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	12272	AZ

General Provider Information

NPI Number	:	1669821427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE CARBAJAL P.T.

Provider Business Mailing Address
First Line	:	950 E RIGGS RD
Second Line	:	SUITE 1
City	:	CHANDLER
State	:	AZ
Zip	:	85249-5399
Country	:	US
Telephone Number	:	480-802-8730
Fax Number	:

Provider Business Practice Location Address
First Line	:	950 E RIGGS RD
Second Line	:	SUITE 1
City	:	CHANDLER
State	:	AZ
Zip	:	85249-5399
Country	:	US
Telephone Number	:	480-802-8730
Fax Number	:

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

Provider Enumeration Date	:	06/11/2016
Last Update Date	:	06/11/2016

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