=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114277431
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. MARLON DE LUNA NAVARRO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2012
-----------------------------------------------------
Last Update Date | 09/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1022 LINCOLN AVENUE APT. 4
-----------------------------------------------------
City | ROCHELLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-512-4194
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 191 CALBEG
-----------------------------------------------------
City | MALASIQUI
-----------------------------------------------------
State | PANGASINAN
-----------------------------------------------------
Zip | 2421
-----------------------------------------------------
Country | PH
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 070018944
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------