=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386869022
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICANOR MABUTAS SOLOMON JR. P.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2250 HICKORY RD SUITE 240
-----------------------------------------------------
City | PLYMOUTH MEETING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19462-1047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-879-4471
-----------------------------------------------------
Fax | 610-834-7525
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 427 BRIGHTON TER
-----------------------------------------------------
City | HOLMES
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19043-1107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-583-4059
-----------------------------------------------------
Fax | 610-583-4059
-----------------------------------------------------
=====================================================
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 | PT015514
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 40QA00734700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------