=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184078511
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FREEMANN BAUTISTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2016
-----------------------------------------------------
Last Update Date | 04/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 BRAKEN AVE
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19808-4380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-757-9956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 BRAKEN AVE
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19808-4380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-757-9956
-----------------------------------------------------
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 | J1-0002096
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------