Healthcare Provider Details

I. General information

NPI: 1578086534
Provider Name (Legal Business Name): ANTHONY ESCOTTO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2017
Last Update Date: 07/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 NORTH CHICAGO AVENUE
GOSHEN IN
46526
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TOWNSHIP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 574-584-3200
  • Fax: 574-584-3204
Mailing address:
  • Phone: 586-416-9100
  • Fax: 586-416-9103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05007567A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: