MEDICARE: MR. ROQUE F ESTIPONA JR. PT

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	4215	TN

General Provider Information

NPI Number	:	1831107804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROQUE F ESTIPONA JR. PT

Provider Business Mailing Address
First Line	:	2552 POPLAR AVE
Second Line	:	SUITE 403
City	:	MEMPHIS
State	:	TN
Zip	:	38112-3852
Country	:	US
Telephone Number	:	901-323-1196
Fax Number	:	901-323-1197

Provider Business Practice Location Address
First Line	:	2552 POPLAR AVE
Second Line	:	SUITE 403
City	:	MEMPHIS
State	:	TN
Zip	:	38112-3852
Country	:	US
Telephone Number	:	901-323-1196
Fax Number	:	901-323-1197

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

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	07/08/2007

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