=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821521923
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NOELLA LIPURA CANLAS PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2017
-----------------------------------------------------
Last Update Date | 04/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12451 NW 15TH PL
-----------------------------------------------------
City | SUNRISE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33323-5229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-383-7842
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 91 E LECAROS EXTENSION UGAC SUR
-----------------------------------------------------
City | TUGUEGARAO
-----------------------------------------------------
State | CAGAYAN VALLEY
-----------------------------------------------------
Zip | 3500
-----------------------------------------------------
Country | PH
-----------------------------------------------------
Telephone | 954-383-7842
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 039960-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------