Healthcare Provider Details

I. General information

NPI: 1053416073
Provider Name (Legal Business Name): FERNANDO VILLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5980 W 71ST ST STE 201
INDIANAPOLIS IN
46278-1785
US

IV. Provider business mailing address

21218 CARLTON CT
NOBLESVILLE IN
46062-8001
US

V. Phone/Fax

Practice location:
  • Phone: 317-388-0800
  • Fax:
Mailing address:
  • Phone: 317-877-0098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05003515A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: