Healthcare Provider Details

I. General information

NPI: 1265305148
Provider Name (Legal Business Name): JUANITO III URETA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2025
Last Update Date: 09/26/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 BENJAMINS WAY
BANGOR ME
04401-2688
US

IV. Provider business mailing address

36 BENJAMINS WAY
BANGOR ME
04401-2688
US

V. Phone/Fax

Practice location:
  • Phone: 689-299-8863
  • Fax:
Mailing address:
  • Phone: 689-299-8863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT6890
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: