Healthcare Provider Details

I. General information

NPI: 1336397447
Provider Name (Legal Business Name): EDGARDO LAHER ELISCUPIDES RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 09/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7495 KESTREL ST
HOBART IN
46342-6950
US

IV. Provider business mailing address

7495 KESTREL STREET
HOBART IN
46342
US

V. Phone/Fax

Practice location:
  • Phone: 219-947-1786
  • Fax:
Mailing address:
  • Phone: 219-947-1786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05008511A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: