MEDICARE: RICARDO WIJNDAL PT

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
1	225100000X	Physical Therapist	005645	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	005645	OTHER	CT	LICENSE

General Provider Information

NPI Number	:	1255723557
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICARDO WIJNDAL PT

Provider Business Mailing Address
First Line	:	14 CHARTER OAK PL
Second Line	:
City	:	HARTFORD
State	:	CT
Zip	:	06106-1961
Country	:	US
Telephone Number	:	860-748-7586
Fax Number	:

Provider Business Practice Location Address
First Line	:	14 CHARTER OAK PL
Second Line	:
City	:	HARTFORD
State	:	CT
Zip	:	06106-1961
Country	:	US
Telephone Number	:	860-748-7586
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2015
Last Update Date	:	02/23/2015

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Directions to “ RICARDO WIJNDAL PT” Practice Location

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