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General NPI Number Information
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NPI Number | 1639389067
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Entity Type | Organization
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Legal Business Name | KIDS FOR LIFE PHYSICAL THERAPY INC.
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Dates
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Enumeration Date | 05/23/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 19167 GLENDALE AVE
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City | SOUTH BEND
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State | IN
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Zip | 46637-2706
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Country | US
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Telephone | 574-273-1442
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Fax | 574-273-1442
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Provider Business Mailing Address
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Address Line | 19167 GLENDALE AVE
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City | SOUTH BEND
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State | IN
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Zip | 46637-2706
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Country | US
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Telephone | 574-273-1442
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Fax | 574-273-1442
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Authorized Official
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Title or Position | PHYSICAL THERAPIST
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Name | MRS. MARIA FILIPINA MARIANO PANTIG
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Credential | PT
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Telephone | 574-273-1442
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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 | 05003203A
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License Number State | IN
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