=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386339653
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLA JO PACE PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2023
-----------------------------------------------------
Last Update Date | 04/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 155 E BURKS DR
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47401-8459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-332-4437
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2714 H ST
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47421-5126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 06000423A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------