Provider Demographics
NPI:1851753651
Name:AVELLANOSA, DIVINO
Entity Type:Individual
Prefix:
First Name:DIVINO
Middle Name:
Last Name:AVELLANOSA
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 1:109 BRIARCLIFF RD
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-3735
Mailing Address - Country:US
Mailing Address - Phone:417-339-4069
Mailing Address - Fax:
Practice Address - Street 1:109 BRIARCLIFF RD
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-3735
Practice Address - Country:US
Practice Address - Phone:417-339-4069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT1650225100000X
2251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics