Healthcare Provider Details

I. General information

NPI: 1700955887
Provider Name (Legal Business Name): ARTURO AVERGONZADO JR. RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3039 CONGRESS DR
KOKOMO IN
46902-8030
US

IV. Provider business mailing address

3039 CONGRESS DR
KOKOMO IN
46902-8030
US

V. Phone/Fax

Practice location:
  • Phone: 765-513-9287
  • Fax: 765-455-2824
Mailing address:
  • Phone: 765-513-9287
  • Fax: 765-455-2824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number05007798A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: