Basic Information
| Provider Information | |||||||||
| NPI: | 1619302510 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGSALDA | ||||||||
| FirstName: | NETHERINE LANN | ||||||||
| MiddleName: | VALENCIA | ||||||||
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| Credential: | RPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | RR 1 BOX 170 | ||||||||
| Address2: | |||||||||
| City: | HILLVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172043036 | ||||||||
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| Practice Location | |||||||||
| Address1: | 620 W BRIDGEPORT ST. | ||||||||
| Address2: | WHITE HALL NURSING AND REHAB | ||||||||
| City: | WHITE HALL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173742144 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2013 | ||||||||
| LastUpdateDate: | 09/10/2013 | ||||||||
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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 | 070.018753 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.