Basic Information
| Provider Information | |||||||||
| NPI: | 1609030493 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELVINIA | ||||||||
| FirstName: | MARIA ROSE LALYN | ||||||||
| MiddleName: | TAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3916 WIND DRIFT DR E | ||||||||
| Address2: | APT 1D | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462543216 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7301 E 16TH STREET | ||||||||
| Address2: | WILDWOOD HEALTH CARE CENTER | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173531290 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2008 | ||||||||
| LastUpdateDate: | 07/14/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05008445A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.