Healthcare Provider Details

I. General information

NPI: 1366218596
Provider Name (Legal Business Name): KIM R BUGLIO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2023
Last Update Date: 11/29/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 MYERS AVE
CONYNGHAM PA
18219-1821
US

IV. Provider business mailing address

PO BOX 305
CONYNGHAM PA
18219-0305
US

V. Phone/Fax

Practice location:
  • Phone: 570-956-1255
  • Fax:
Mailing address:
  • Phone: 570-956-1255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberTEI001926
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: