Healthcare Provider Details

I. General information

NPI: 1053849596
Provider Name (Legal Business Name): ESTHER MICU FUNTANILLA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2017
Last Update Date: 05/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 ST ANTHONY WAY
PENDLETON OR
97801-3800
US

IV. Provider business mailing address

1211 SW 21ST ST APT 106
PENDLETON OR
97801-4478
US

V. Phone/Fax

Practice location:
  • Phone: 541-278-6610
  • Fax:
Mailing address:
  • Phone: 541-701-7661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6619
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: