Healthcare Provider Details

I. General information

NPI: 1164619862
Provider Name (Legal Business Name): MAGEN L WINDEL LICENSED PHYSICAL TH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 03/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 OLD COUNTRY CLUB RD NW
ROANOKE VA
24017-2927
US

IV. Provider business mailing address

5638 INGLESIDE DR
ROANOKE VA
24018-4814
US

V. Phone/Fax

Practice location:
  • Phone: 540-387-4311
  • Fax: 540-387-4311
Mailing address:
  • Phone: 540-529-2114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306602172
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: