=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205029170
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASIN E KNIGHTS PHYSICAL THERAPIST
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2007
-----------------------------------------------------
Last Update Date | 08/23/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 W MAPLE ST
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87401-5630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-325-5011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14413 SAN PAOLO LN
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28277-3379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-315-9960
-----------------------------------------------------
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 | 8400
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------