Basic Information
Provider Information
NPI: 1003000555
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PATEL
FirstName: MANISHA
MiddleName: AJIT
NamePrefix: MRS.
NameSuffix:  
Credential: DPT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1401 E STATE ST
Address2:  
City: ROCKFORD
State: IL
PostalCode: 611042315
CountryCode: US
TelephoneNumber: 8154894470
FaxNumber: 8154905858
Practice Location
Address1: 1401 E STATE ST
Address2:  
City: ROCKFORD
State: IL
PostalCode: 611042315
CountryCode: US
TelephoneNumber: 8154894470
FaxNumber: 8154905858
Other Information
ProviderEnumerationDate: 08/28/2007
LastUpdateDate: 08/28/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X070.01425ILY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

ID Information
IDTypeStateIssuerDescription
070.0142501 STATE OF ILLINOISOTHER


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