=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144987686
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IVAN QUIBETE BAJALA PT, DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2021
-----------------------------------------------------
Last Update Date | 11/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11523 OXCROFT CT
-----------------------------------------------------
City | NEW PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34654-4666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-457-5969
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11523 OXCROFT CT
-----------------------------------------------------
City | NEW PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34654-4666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-457-5969
-----------------------------------------------------
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 | 16346
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------