=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528640646
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FRANCISCO GABRIEL SOTELO ACEVES PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2021
-----------------------------------------------------
Last Update Date | 04/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3475 S ALPINE RD
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61109-2604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-261-9047
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 SUMMIT ST APT 7
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-4257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-495-2233
-----------------------------------------------------
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 | 160.009140
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------