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General NPI Number Information
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NPI Number | 1467611905
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Entity Type | Individual
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Provider Name | CARL JASON ANTONIL VILLANUEVA PT
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Gender | Male
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Dates
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Enumeration Date | 06/09/2008
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Last Update Date | 06/09/2008
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Provider Practice Location Address
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Address Line | 1839 ONSLOW DR
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City | JACKSONVILLE
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State | NC
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Zip | 28540-5906
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Country | US
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Telephone | 910-455-3610
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Fax |
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Provider Business Mailing Address
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Address Line | 2015 HUNTERS RIDGE DR
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City | MIDWAY PARK
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State | NC
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Zip | 28544-1635
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Country | US
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Telephone | 910-577-1210
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 8040
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License Number State | NC
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