=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578765756
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK JOHN KAPEC LPTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7233 WHIPPLE AVE NW
-----------------------------------------------------
City | NORTH CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44720-7137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-498-8200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29106 EDGEWOOD DR
-----------------------------------------------------
City | WILLOWICK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44095-4738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-944-5383
-----------------------------------------------------
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 | PTA04114
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------