Healthcare Provider Details

I. General information

NPI: 1710484506
Provider Name (Legal Business Name): EDWARD REGINALD ONOFRIO PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 04/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S OCOTILLO AVE
BENSON AZ
85602-6401
US

IV. Provider business mailing address

PO BOX 18938
TUCSON AZ
85731-8938
US

V. Phone/Fax

Practice location:
  • Phone: 520-586-9111
  • Fax:
Mailing address:
  • Phone: 520-808-1930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number1075
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: