Healthcare Provider Details

I. General information

NPI: 1215776455
Provider Name (Legal Business Name): PLAYWELL PEDIATRIC THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7047 N 15TH ST
DALTON GARDENS ID
83815-9595
US

IV. Provider business mailing address

7047 N 15TH ST
DALTON GARDENS ID
83815-9595
US

V. Phone/Fax

Practice location:
  • Phone: 562-212-6891
  • Fax:
Mailing address:
  • Phone: 562-212-6891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LANMANA PARYS-WOLODKEWITSCH
Title or Position: OWNER
Credential:
Phone: 562-212-6891