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General NPI Number Information
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NPI Number | 1265188072
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Entity Type | Individual
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Provider Name | KHEA MEL ESTORNINOS PERALES PTA
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Gender | Male
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Dates
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Enumeration Date | 03/02/2022
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Last Update Date | 03/02/2022
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Provider Practice Location Address
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Address Line | 4139 70TH ST APT WOODSIDE
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City | WOODSIDE
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State | NY
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Zip | 11377-8122
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Country | US
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Telephone | 719-660-7641
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Fax |
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Provider Business Mailing Address
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Address Line | 4139 70TH ST APT WOODSIDE
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City | WOODSIDE
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State | NY
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Zip | 11377-8122
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Country | US
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Telephone | 719-660-7641
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 013089-01
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License Number State | NY
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