Provider Demographics
NPI:1578818183
Name:GONCALVES, IZILDINHA R (PT)
Entity Type:Individual
Prefix:
First Name:IZILDINHA
Middle Name:R
Last Name:GONCALVES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ZIL
Other - Middle Name:
Other - Last Name:GONCALVES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:60 SHUFORD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NC
Mailing Address - Zip Code:28722-7406
Mailing Address - Country:US
Mailing Address - Phone:828-894-0277
Mailing Address - Fax:828-894-0278
Practice Address - Street 1:6400 HIGHWAY 9
Practice Address - Street 2:UNIT D
Practice Address - City:INMAN
Practice Address - State:SC
Practice Address - Zip Code:29349-6927
Practice Address - Country:US
Practice Address - Phone:864-699-9441
Practice Address - Fax:864-699-9279
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3596225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0231Medicaid
SC8274Medicare PIN