Healthcare Provider Details

I. General information

NPI: 1750409363
Provider Name (Legal Business Name): NOEL EULOGIO NATIVIDAD PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 LONG RUN RD
PINE GROVE PA
17963-9020
US

IV. Provider business mailing address

918 LONG RUN RD
PINE GROVE PA
17963-9020
US

V. Phone/Fax

Practice location:
  • Phone: 570-739-2176
  • Fax:
Mailing address:
  • Phone: 570-739-2176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT016277
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number025322-1
License Number StateNY

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: