Healthcare Provider Details

I. General information

NPI: 1265824544
Provider Name (Legal Business Name): JONATHAN JOSEPH VARDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2015
Last Update Date: 02/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FATHER DEVALLES BLVD SUITE 401
FALL RIVER MA
02723-1511
US

IV. Provider business mailing address

1399 PHILLIPS RD APARTMENT G80
NEW BEDFORD MA
02745-1937
US

V. Phone/Fax

Practice location:
  • Phone: 508-673-5500
  • Fax:
Mailing address:
  • Phone: 508-965-3689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number8961
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: