Provider Demographics
NPI:1639593296
Name:AGALO-OS, JOHN CARLO
Entity Type:Individual
Prefix:
First Name:JOHN CARLO
Middle Name:
Last Name:AGALO-OS
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 1:25106 W 6 MILE RD
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-2706
Mailing Address - Country:US
Mailing Address - Phone:313-541-1172
Mailing Address - Fax:
Practice Address - Street 1:25106 W 6 MILE RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48240-2706
Practice Address - Country:US
Practice Address - Phone:313-541-1172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011938225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist