Provider Demographics
NPI:1265841613
Name:SALAS, JOSE (ATC, CES, CSCS)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:SALAS
Suffix:
Gender:M
Credentials:ATC, CES, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 ALLISON LN
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-5266
Mailing Address - Country:US
Mailing Address - Phone:636-212-2508
Mailing Address - Fax:
Practice Address - Street 1:202 ALLISON LN
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-5266
Practice Address - Country:US
Practice Address - Phone:636-212-2508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002364A2255A2300X
FLAL 38512255A2300X
TXAT54082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer