Healthcare Provider Details

I. General information

NPI: 1689905176
Provider Name (Legal Business Name): CORAZON MANGLANLAN OBILLO P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CORAZON OBILLO P.T.

II. Dates (important events)

Enumeration Date: 01/22/2010
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 SE 92ND COURT
VANCOUVER WA
98664
US

IV. Provider business mailing address

1609 SE 92ND COURT
VANCOUVER WA
98664
US

V. Phone/Fax

Practice location:
  • Phone: 360-737-7527
  • Fax: 360-694-8613
Mailing address:
  • Phone: 360-917-8562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6112
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number60113682
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: