Provider Demographics
NPI:1205018256
Name:DACILLO, REX
Entity Type:Individual
Prefix:MR
First Name:REX
Middle Name:
Last Name:DACILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 HAWK RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-1353
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:42 HAWK RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-1353
Practice Address - Country:US
Practice Address - Phone:609-919-1930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-02
Last Update Date:2014-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPTA40QB00242200225200000X
PATEI002499225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant