Provider Demographics
NPI:1669906780
Name:BALTAZAR, RIO CAMILLE
Entity type:Individual
Prefix:
First Name:RIO CAMILLE
Middle Name:
Last Name:BALTAZAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2619 BURNS PL
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-5621
Mailing Address - Country:US
Mailing Address - Phone:817-773-1510
Mailing Address - Fax:
Practice Address - Street 1:2619 BURNS PL
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-5621
Practice Address - Country:US
Practice Address - Phone:817-773-1510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-14
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1239581225100000X
NJ40QA01787400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist