Healthcare Provider Details

I. General information

NPI: 1255503330
Provider Name (Legal Business Name): MARY GRACE Y SOLIS-ALTAVAS P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 03/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5860 GOLDEN GATE PKWY
NAPLES FL
34116-7459
US

IV. Provider business mailing address

3713 OAK HOLLOW DR
NEWBERG OR
97132-7478
US

V. Phone/Fax

Practice location:
  • Phone: 239-455-9525
  • Fax:
Mailing address:
  • Phone: 503-554-9318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT23901
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: