Provider Demographics
NPI:1205172269
Name:MADRID, HENRICO MARC ENVERGA (BSPT)
Entity type:Individual
Prefix:
First Name:HENRICO MARC
Middle Name:ENVERGA
Last Name:MADRID
Suffix:
Gender:M
Credentials:BSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7443 HARTINGTON PL
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46259-5805
Mailing Address - Country:US
Mailing Address - Phone:317-862-1490
Mailing Address - Fax:
Practice Address - Street 1:904 E 11TH ST
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:IN
Practice Address - Zip Code:46173-1368
Practice Address - Country:US
Practice Address - Phone:765-932-2974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008201A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist