MEDICARE: CHARITO APOLONIO MINA P.T.

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	0687	OR

General Provider Information

NPI Number	:	1386690600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARITO APOLONIO MINA P.T.

Provider Business Mailing Address
First Line	:	1200 CORPORATE DR
Second Line	:	STE 400
City	:	BIRMINGHAM
State	:	AL
Zip	:	35242-5424
Country	:	US
Telephone Number	:	423-238-8923
Fax Number	:	423-954-7399

Provider Business Practice Location Address
First Line	:	3007 NE WEST DEVILS LAKE RD
Second Line	:
City	:	LINCOLN CITY
State	:	OR
Zip	:	97367-5131
Country	:	US
Telephone Number	:	541-994-6252
Fax Number	:	541-994-6355

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

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	07/26/2018

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