=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629606843
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | P.O.C. CONVERTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2020
-----------------------------------------------------
Last Update Date | 04/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9234 ABBEY LN
-----------------------------------------------------
City | IRWIN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15642-4393
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-215-6685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9234 ABBEY LN
-----------------------------------------------------
City | IRWIN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15642-4393
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-215-6685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT, C.E.O.
-----------------------------------------------------
Name | MR. JONATHAN JAMES JIANCRISTOFORO
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 412-215-6685
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251S0007X
-----------------------------------------------------
Taxonomy Name | Sports Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------