Healthcare Provider Details

I. General information

NPI: 1720516933
Provider Name (Legal Business Name): KEVIN RAJ VILLEGAS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2017
Last Update Date: 06/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 FORREST AVE STE 101
DOVER DE
19904-3483
US

IV. Provider business mailing address

119 PROFESSIONAL CTR BLDG 1265
INDIANA PA
15701-3586
US

V. Phone/Fax

Practice location:
  • Phone: 302-735-4900
  • Fax: 302-735-4671
Mailing address:
  • Phone: 724-801-8095
  • Fax: 724-801-8147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberJ1-0003719
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: