MEDICARE: DAVID SEQUINO BAMBILLA DPT

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
2	225100000X	Physical Therapist	PTL28021	MA

General Provider Information

NPI Number	:	1871372789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID SEQUINO BAMBILLA DPT

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1661 WORCESTER RD STE 105
Second Line	:
City	:	FRAMINGHAM
State	:	MA
Zip	:	01701-5405
Country	:	US
Telephone Number	:	508-626-2600
Fax Number	:

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

Provider Enumeration Date	:	09/28/2023
Last Update Date	:	10/16/2024

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