MEDICARE: MERCED M. VILLANUEVA 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	02245	MO

General Provider Information

NPI Number	:	1881811743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MERCED M. VILLANUEVA PT

Provider Business Mailing Address
First Line	:	2905 CANTABERRY DR
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109-9273
Country	:	US
Telephone Number	:	573-634-7983
Fax Number	:	573-634-7983

Provider Business Practice Location Address
First Line	:	2905 CANTABERRY DR
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109-9273
Country	:	US
Telephone Number	:	573-634-7983
Fax Number	:	573-634-7983

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

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	07/08/2007

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