Basic Information
| Provider Information | |||||||||
| NPI: | 1487931184 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANDA | ||||||||
| FirstName: | RAYMOND RENE | ||||||||
| MiddleName: | LUCIO | ||||||||
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| Credential: | RPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6301 UNIVERSITY COMMONS | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466351571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5749682851 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6301 UNIVERSITY COMMONS | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466351571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5749682851 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2011 | ||||||||
| LastUpdateDate: | 11/08/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05005612A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251P0200X | 02179 | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
No ID Information.