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NPI Code Detail

MEDICARE: MR. WIRT RAINIER VILLANUEVA PHYSICAL THERAPIST

MEDICARE: MR. WIRT RAINIER VILLANUEVA PHYSICAL THERAPIST
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12251G0304XGeriatric Physical Therapist40QA01009100NJ

General Provider Information

NPI Number : 1194911933
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. WIRT RAINIER VILLANUEVA PHYSICAL THERAPIST
Provider Business Mailing Address
First Line : 12 ETTY CT
Second Line :
City : MANCHESTER
State : NJ
Zip : 08759-5918
Country : US
Telephone Number : 732-323-8628
Fax Number :
Provider Business Practice Location Address
First Line : 75 OLD TOMS RIVER RD
Second Line :
City : BRICK
State : NJ
Zip : 08723-7800
Country : US
Telephone Number : 732-451-1000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/14/2007
Last Update Date : 09/14/2007

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