Healthcare Provider Details

I. General information

NPI: 1740709807
Provider Name (Legal Business Name): JOHN BAZZONI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2017
Last Update Date: 09/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 N WALNUT ST
NORTH MANCHESTER IN
46962-1857
US

IV. Provider business mailing address

605 N WALNUT ST
NORTH MANCHESTER IN
46962-1857
US

V. Phone/Fax

Practice location:
  • Phone: 260-982-1985
  • Fax: 260-982-1994
Mailing address:
  • Phone: 260-982-1985
  • Fax: 260-982-1994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05006511A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: