Basic Information
| Provider Information | |||||||||
| NPI: | 1235263591 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAILLA | ||||||||
| FirstName: | MATHEW | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 807 VILLAGE CIR | ||||||||
| Address2: | APT C | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197134904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3377649151 | ||||||||
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| Practice Location | |||||||||
| Address1: | 053 MCKINLY LAB | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 19716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3028318893 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 01/10/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 07164 | LA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251S0007X | J1-0002660 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports |
No ID Information.