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General NPI Number Information
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NPI Number | 1265798086
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Entity Type | Individual
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Provider Name | BONIFACIO WENCESLAO JR. PT
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Gender | Male
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Dates
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Enumeration Date | 04/05/2012
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Last Update Date | 02/04/2021
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Provider Practice Location Address
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Address Line | 2656 SOUTH RD STE C
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City | POUGHKEEPSIE
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State | NY
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Zip | 12601-5279
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Country | US
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Telephone | 845-849-1082
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Fax |
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Provider Business Mailing Address
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Address Line | 2656 SOUTH RD STE C
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City | POUGHKEEPSIE
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State | NY
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Zip | 12601-5279
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Country | US
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Telephone | 845-849-1082
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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 | 171W00000X
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Taxonomy Name | Contractor
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License Number | 032312
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 032312
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License Number State | NY
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