Basic Information
| Provider Information | |||||||||
| NPI: | 1982114534 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SNIDER | ||||||||
| FirstName: | DUSTIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 203 | ||||||||
| Address2: | |||||||||
| City: | THOMAS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 262920203 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5535 S WILLIAMSON BLVD STE 774 | ||||||||
| Address2: | |||||||||
| City: | PORT ORANGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321288321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882652680 | ||||||||
| FaxNumber: | 3869447202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2017 | ||||||||
| LastUpdateDate: | 10/10/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT003808 | WV | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2305211411 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.