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General NPI Number Information
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NPI Number | 1063814309
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Entity Type | Individual
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Provider Name | LAKSHMI KALYANI GUDAVALLI PT
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Gender | Female
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Dates
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Enumeration Date | 09/18/2014
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Last Update Date | 09/18/2014
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Provider Practice Location Address
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Address Line | 275 E CARL SANDBURG DRIVE MARIGOLD REHABILITATION
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City | GALESBURG
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State | IL
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Zip | 61401
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Country | US
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Telephone | 309-344-1151
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Fax |
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Provider Business Mailing Address
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Address Line | 2834 VILLA CT
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City | BETTENDORF
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State | IA
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Zip | 52722-7554
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Country | US
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Telephone | 563-639-2486
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | 070020357
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License Number State | IL
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