Healthcare Provider Details

I. General information

NPI: 1902141120
Provider Name (Legal Business Name): AJAUNIE DEAGO SILPOT PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2012
Last Update Date: 11/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 WEST AVE INNOVATIVE HEALTH AND REHABILITATION
NORWALK CT
06850-4020
US

IV. Provider business mailing address

50 FOREST ST APT 1107
STAMFORD CT
06901-1871
US

V. Phone/Fax

Practice location:
  • Phone: 203-852-9903
  • Fax:
Mailing address:
  • Phone: 203-550-2384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1291
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: