MEDICARE: PEDIATRIC LINKS,LLC

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	2251P0200X	Pediatric Physical Therapist	PT05002613A	IN
2	261QD1600X	Developmental Disabilities Clinic/Center	PT05002613A	IN

General Provider Information

NPI Number	:	1720370794
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC LINKS,LLC

Provider Business Mailing Address
First Line	:	7317 W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-6237
Country	:	US
Telephone Number	:	260-418-8051
Fax Number	:	260-489-3704

Provider Business Practice Location Address
First Line	:	7317 W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-6237
Country	:	US
Telephone Number	:	260-418-8051
Fax Number	:	260-489-3704

Authorized Official
Title or Position	:	ADMINISTRATOR/OWNER/PRACTITIONER
Name	:	AGNES LUCAS VIGILIA-MARAYA
Credential	:	P.T.
Telephone Number	:	260-418-8051

Provider Enumeration Date	:	05/10/2011
Last Update Date	:	05/10/2011

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