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General NPI Number Information
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NPI Number | 1548510357
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Entity Type | Individual
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Provider Name | PONCIANO PORMENTIRA JR. DPT
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Gender | Male
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Dates
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Enumeration Date | 09/19/2012
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Last Update Date | 09/19/2012
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Provider Practice Location Address
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Address Line | 929 STACY BURK DRIVE
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City | FLORA
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State | IL
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Zip | 62839
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Country | US
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Telephone | 618-662-8060
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Fax | 618-662-8080
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Provider Business Mailing Address
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Address Line | 124 E 4TH ST
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City | FLORA
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State | IL
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Zip | 62839-2009
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Country | US
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Telephone |
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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 | 070.015245
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License Number State | IL
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