Healthcare Provider Details

I. General information

NPI: 1780092064
Provider Name (Legal Business Name): ADAM KAGARISE D.P.T
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2014
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 BOARDMAN CANFIELD RD BUILDING P UNIT 1
BOARDMAN OH
44512-4300
US

IV. Provider business mailing address

8073 WASHINGTON VILLAGE DRIVE SUITE 110
DAYTON OH
45458-1847
US

V. Phone/Fax

Practice location:
  • Phone: 330-726-7404
  • Fax:
Mailing address:
  • Phone: 937-813-8052
  • Fax: 937-813-8056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number014974
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: