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General NPI Number Information
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NPI Number | 1780743302
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Entity Type | Organization
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Legal Business Name | BUSTLETON PHYSICAL & SPORTS REHAB
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Dates
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Enumeration Date | 12/08/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 9622 BUSTLETON AVE STE 4
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City | PHILADELPHIA
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State | PA
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Zip | 19115-3100
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Country | US
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Telephone | 215-677-8258
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Fax | 215-673-4966
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Provider Business Mailing Address
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Address Line | 9622 BUSTLETON AVE STE 4
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City | PHILADELPHIA
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State | PA
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Zip | 19115-3100
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Country | US
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Telephone | 215-677-8258
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Fax | 215-673-4966
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Authorized Official
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Title or Position | OWNER AND PRESIDENT
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Name | DONNA MARIE GAVARONE
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Credential | DO
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Telephone | 215-676-7067
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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 |
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License Number State |
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