MEDICARE: CITADEL CABALAN TIBON 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	027533	NY

General Provider Information

NPI Number	:	1538474341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CITADEL CABALAN TIBON PT

Provider Business Mailing Address
First Line	:	131 W 135TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10030-2922
Country	:	US
Telephone Number	:	212-281-8678
Fax Number	:

Provider Business Practice Location Address
First Line	:	131 W 135TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10030-2922
Country	:	US
Telephone Number	:	212-281-8678
Fax Number	:

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

Provider Enumeration Date	:	08/17/2010
Last Update Date	:	08/17/2010

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