Provider Demographics
NPI:1598540718
Name:VILLALUZ, VON CARLO VIAJE (PT)
Entity Type:Individual
Prefix:
First Name:VON CARLO
Middle Name:VIAJE
Last Name:VILLALUZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20960 STARBRICK RD
Mailing Address - Street 2:
Mailing Address - City:EDWARDSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49112-9211
Mailing Address - Country:US
Mailing Address - Phone:347-886-4261
Mailing Address - Fax:
Practice Address - Street 1:20960 STARBRICK RD
Practice Address - Street 2:
Practice Address - City:EDWARDSBURG
Practice Address - State:MI
Practice Address - Zip Code:49112-9211
Practice Address - Country:US
Practice Address - Phone:347-886-4261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050964225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist