Healthcare Provider Details

I. General information

NPI: 1174745038
Provider Name (Legal Business Name): JOHN R. DE BITETTO MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 10/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 MAIN STREET
MANCHESTER VT
05254
US

IV. Provider business mailing address

PO BOX 2493
MANCHESTER CENTER VT
05255-2493
US

V. Phone/Fax

Practice location:
  • Phone: 802-768-8369
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number040.0102092
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: