=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538499462
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLO AUSTRIA BUQUIZ P.T.A.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/24/2009
-----------------------------------------------------
Last Update Date | 12/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 W FLETCHER ST APT 227
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-3247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-493-0637
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1301 W FLETCHER ST APT 227
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-3247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-493-0637
-----------------------------------------------------
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 | 160.005081
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------