MEDICARE: REBECCAH JEAN CENTOLA PTA

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	225200000X	Physical Therapy Assistant	133853	AK

General Provider Information

NPI Number	:	1700559283
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCAH JEAN CENTOLA PTA

Provider Business Mailing Address
First Line	:	591 SLATER DR
Second Line	:
City	:	FAIRBANKS
State	:	AK
Zip	:	99701-3444
Country	:	US
Telephone Number	:	541-633-0723
Fax Number	:

Provider Business Practice Location Address
First Line	:	3455 REWAK DR STE 106
Second Line	:
City	:	FAIRBANKS
State	:	AK
Zip	:	99709-5024
Country	:	US
Telephone Number	:	907-457-5322
Fax Number	:

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

Provider Enumeration Date	:	07/29/2021
Last Update Date	:	07/29/2021

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