Provider Demographics
NPI:1356673305
Name:PAWULA, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:PAWULA
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 1:4702 LINDBLOOM LN
Mailing Address - Street 2:
Mailing Address - City:CHERRY VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61016-9112
Mailing Address - Country:US
Mailing Address - Phone:630-740-6293
Mailing Address - Fax:
Practice Address - Street 1:917 BEVILLE RD
Practice Address - Street 2:SUITE G
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-1712
Practice Address - Country:US
Practice Address - Phone:386-756-4395
Practice Address - Fax:866-426-2811
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017268225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist