Healthcare Provider Details

I. General information

NPI: 1972792513
Provider Name (Legal Business Name): LILIAN DAVALOS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2007
Last Update Date: 10/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26181 PARKSLEY RD
PARKSLEY VA
23421-3723
US

IV. Provider business mailing address

8808 SURREY CT
ALEXANDRIA VA
22309-2243
US

V. Phone/Fax

Practice location:
  • Phone: 256-714-8440
  • Fax:
Mailing address:
  • Phone: 703-307-9553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: