Basic Information
| Provider Information | |||||||||
| NPI: | 1134701485 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PURINO | ||||||||
| FirstName: | ELEANOR | ||||||||
| MiddleName: | |||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 500 | ||||||||
| Address2: | |||||||||
| City: | BROOKEVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208330500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014988100 | ||||||||
| FaxNumber: | 3014980009 | ||||||||
| Practice Location | |||||||||
| Address1: | 14409 GREENVIEW DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207084213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014988100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2021 | ||||||||
| LastUpdateDate: | 04/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | A5283 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | A5283 | 01 | MD | DEPARTMENT OF HEALTH , STATE OF MARYLAND | OTHER |