Basic Information
| Provider Information | |||||||||
| NPI: | 1811595234 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICARLO | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | VINCENT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 633 W RITTENHOUSE ST APT B120 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191444316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109089775 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3485 DAVISVILLE RD | ||||||||
| Address2: | |||||||||
| City: | HATBORO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190404220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158300400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2020 | ||||||||
| LastUpdateDate: | 10/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | TE012508 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.