Provider Demographics
NPI:1598951493
Name:DEVILLA, EUSTAQUIO IBIAS (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:EUSTAQUIO
Middle Name:IBIAS
Last Name:DEVILLA
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 TOMAHAWK MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4290
Mailing Address - Country:US
Mailing Address - Phone:757-589-5264
Mailing Address - Fax:
Practice Address - Street 1:2401 TOMAHAWK MEADOWS DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4290
Practice Address - Country:US
Practice Address - Phone:757-589-5264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
B1362743146N00000X
MD18054225100000X
VA2305204220225100000X
SC2572225100000X
TN0000004337225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic