Healthcare Provider Details

I. General information

NPI: 1740797828
Provider Name (Legal Business Name): ROY H VELASCO JR. PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2018
Last Update Date: 01/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 GEORGIA AVE STE LL1
SILVER SPRING MD
20910-3722
US

IV. Provider business mailing address

112 MISSOURI CT
FREDERICK MD
21702-6450
US

V. Phone/Fax

Practice location:
  • Phone: 301-587-5333
  • Fax:
Mailing address:
  • Phone: 301-305-2963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA4162
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: