Healthcare Provider Details

I. General information

NPI: 1720438666
Provider Name (Legal Business Name): ANTHONY MOLASCON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 MAIN ST
BELLEVILLE MI
48111-2650
US

IV. Provider business mailing address

PO BOX 412031
BOSTON MA
02241-4909
US

V. Phone/Fax

Practice location:
  • Phone: 734-489-6440
  • Fax: 810-632-1001
Mailing address:
  • Phone: 914-294-4050
  • Fax: 631-760-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501017734
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: