Healthcare Provider Details

I. General information

NPI: 1255472692
Provider Name (Legal Business Name): CHERI LEIGH FAGAN OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHERI LEIGH WELLS OTRL

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 W TAMARACK ST PINDAR PHYSICAL THERAPY INC
HAZLETON PA
18201
US

IV. Provider business mailing address

PO BOX 384 306 EAST 1ST ST
MIFFLINVILLE PA
18631
US

V. Phone/Fax

Practice location:
  • Phone: 570-401-6566
  • Fax: 570-501-2435
Mailing address:
  • Phone: 570-752-4744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberOC006277L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierP00298278
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: