MEDICARE: AILEEN JOY MARAVILLA LAGUNILLA 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	012688-1	NY

General Provider Information

NPI Number	:	1861441669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AILEEN JOY MARAVILLA LAGUNILLA PT

Provider Business Mailing Address
First Line	:	2113 SALISBURY PARK DR
Second Line	:
City	:	WESTBURY
State	:	NY
Zip	:	11590-6313
Country	:	US
Telephone Number	:	516-312-6474
Fax Number	:

Provider Business Practice Location Address
First Line	:	122 E 23RD ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10010-4516
Country	:	US
Telephone Number	:	212-677-7400
Fax Number	:	212-529-2071

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

Provider Enumeration Date	:	05/09/2006
Last Update Date	:	07/08/2007

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