Healthcare Provider Details

I. General information

NPI: 1063719144
Provider Name (Legal Business Name): JOHN WESLY BOWLIN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2011
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1463 17TH AVE
MITCHELL NE
69357-1429
US

IV. Provider business mailing address

1463 17TH AVE
MITCHELL NE
69357-1429
US

V. Phone/Fax

Practice location:
  • Phone: 308-623-1313
  • Fax:
Mailing address:
  • Phone: 308-623-1313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2684
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: