Healthcare Provider Details

I. General information

NPI: 1588962294
Provider Name (Legal Business Name): THOMAS JOSEPH CANTWELL III LPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2011
Last Update Date: 03/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 NAPA AVE APT 2
MORRO BAY CA
93442-2563
US

IV. Provider business mailing address

PO BOX 1144
MORRO BAY CA
93443-1144
US

V. Phone/Fax

Practice location:
  • Phone: 206-414-1938
  • Fax:
Mailing address:
  • Phone: 206-414-1938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberPT22730
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: