MEDICARE: MRS. MONNETT PETILOS LPT

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	05007695A	IN

General Provider Information

NPI Number	:	1962619767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MONNETT PETILOS LPT

Provider Business Mailing Address
First Line	:	1213 BLUFF POINTE WAY
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-2058
Country	:	US
Telephone Number	:	260-490-7049
Fax Number	:

Provider Business Practice Location Address
First Line	:	2872 E. DUPONT RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825
Country	:	US
Telephone Number	:	260-497-0838
Fax Number	:	260-497-9088

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

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	07/08/2007

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