Healthcare Provider Details

I. General information

NPI: 1659006294
Provider Name (Legal Business Name): ANGELICA MARCOS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1023 W MAIN ST
VEVAY IN
47043-9192
US

IV. Provider business mailing address

5641 W HOLLY HILLS RD
HANOVER IN
47243-9224
US

V. Phone/Fax

Practice location:
  • Phone: 812-427-2803
  • Fax:
Mailing address:
  • Phone: 812-493-3426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06005908A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: