Healthcare Provider Details

I. General information

NPI: 1831177930
Provider Name (Legal Business Name): IVAN R SALAZAR PT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BARRON DR
INSTITUTE WV
25112-1004
US

IV. Provider business mailing address

PO BOX 1004 BARRON DR
INSTITUTE WV
25112-1004
US

V. Phone/Fax

Practice location:
  • Phone: 304-766-4869
  • Fax: 304-766-4867
Mailing address:
  • Phone: 304-766-4869
  • Fax: 304-766-4867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number000674
License Number StateWV

VII. Legacy identifiers

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

# 1
Identifier0001722910
Identifier TypeOTHER
Identifier StateWV
Identifier IssuerMTN ST BC/BS PROVIDER
# 2
Identifier000674
Identifier TypeOTHER
Identifier StateWV
Identifier IssuerWV BD OF PT
# 3
Identifier0157318000
Identifier TypeMEDICAID
Identifier StateWV
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: