Healthcare Provider Details

I. General information

NPI: 1225611122
Provider Name (Legal Business Name): EMILSON THEODORE HILARIO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2021
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11340 PEMBROOKE SQ STE 211
WALDORF MD
20603-4808
US

IV. Provider business mailing address

11340 PEMBROOKE SQ STE 211
WALDORF MD
20603-4808
US

V. Phone/Fax

Practice location:
  • Phone: 240-530-8188
  • Fax: 301-638-0470
Mailing address:
  • Phone: 240-530-8188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA4698
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: