=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952880601
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MITALI NIMESH PATEL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2018
-----------------------------------------------------
Last Update Date | 08/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 LAUDERDALE DR
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23238-3933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-521-9271
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2005 CIRCLESTONE CT
-----------------------------------------------------
City | SOUTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23834-5386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 2305209318
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------