Healthcare Provider Details

I. General information

NPI: 1053400903
Provider Name (Legal Business Name): MRS. SHANTHI V VENKAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 GLENDALE AVE DEPARTMENT OF VETERANS AFFAIRS
TOLEDO OH
41614
US

IV. Provider business mailing address

13984 ECKEL JUNCTION RD
PERRYSBURG OH
43551-5711
US

V. Phone/Fax

Practice location:
  • Phone: 419-259-2037
  • Fax: 419-259-2008
Mailing address:
  • Phone: 418-872-1644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251C2600X
TaxonomyCardiopulmonary Physical Therapist
License Number5501005886
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: