Basic Information
| Provider Information | |||||||||
| NPI: | 1427110717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IBRAHIM | ||||||||
| FirstName: | M A ZURITA | ||||||||
| MiddleName: | HERNANDO | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 WASHINGTON STREET | ||||||||
| Address2: | PO BOX 536 | ||||||||
| City: | RAVENSWOOD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042738071 | ||||||||
| FaxNumber: | 3042738015 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 WASHINGTON STREET | ||||||||
| Address2: | |||||||||
| City: | RAVENSWOOD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042738071 | ||||||||
| FaxNumber: | 3042738015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 12/17/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 001137 | WV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0157410000 | 05 | WV | MEDICAID | 0240071000 | 05 | WV | MEDICAID |