=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114018504
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NEIL EDWARD VILLANUEVA P.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23432 ROBINBROOK PL
-----------------------------------------------------
City | DIAMOND BAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91765-2634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-861-6784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23432 ROBINBROOK PL
-----------------------------------------------------
City | DIAMOND BAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91765-2634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-861-6784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 29456
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------