Basic Information
| Provider Information | |||||||||
| NPI: | 1285944561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORMILLEZA | ||||||||
| FirstName: | MODESTO KING ANDREW | ||||||||
| MiddleName: | ESGUERRA | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | V | ||||||||
| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4001 POTTER ST APT 47 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974054583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419125595 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 735 S 2ND ST | ||||||||
| Address2: | |||||||||
| City: | CRESWELL | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974267507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418953333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2010 | ||||||||
| LastUpdateDate: | 10/20/2010 | ||||||||
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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 | 225XP0019X | 260743 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation |
No ID Information.