Healthcare Provider Details

I. General information

NPI: 1760294789
Provider Name (Legal Business Name): CHRISTIAN KYLE GERARDO DECAMPONG PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2025
Last Update Date: 01/25/2025
Certification Date: 01/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 504816
SAIPAN MP
96950-4309
US

IV. Provider business mailing address

PO BOX 503361
SAIPAN MP
96950-3361
US

V. Phone/Fax

Practice location:
  • Phone: 670-323-6877
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number011212
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0066
License Number StateMP

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: