Healthcare Provider Details

I. General information

NPI: 1811301815
Provider Name (Legal Business Name): BOITUMELO JOHN EDMUND MASHALA P.T.A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 CHESTNUT CT APT H
GREENCASTLE IN
46135-7309
US

IV. Provider business mailing address

1150 CHESTNUT CT APT H
GREENCASTLE IN
46135-7309
US

V. Phone/Fax

Practice location:
  • Phone: 574-596-1539
  • Fax:
Mailing address:
  • Phone: 574-596-1539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06004423A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: