Provider Demographics
NPI:1043337215
Name:VILLORENTE, RYAN GUEVARA (PTA)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:GUEVARA
Last Name:VILLORENTE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MERKEL DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3126
Mailing Address - Country:US
Mailing Address - Phone:973-262-4399
Mailing Address - Fax:
Practice Address - Street 1:21 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1501
Practice Address - Country:US
Practice Address - Phone:973-736-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00235000225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant