Provider Demographics
NPI:1750530895
Name:PINUNGGAN, RIA ERA MONTEROS
Entity type:Individual
Prefix:
First Name:RIA ERA
Middle Name:MONTEROS
Last Name:PINUNGGAN
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 1:6150 HARDY AVE # 2G12
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-6212
Mailing Address - Country:US
Mailing Address - Phone:231-313-1852
Mailing Address - Fax:
Practice Address - Street 1:6150 HARDY AVE
Practice Address - Street 2:2G12
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6212
Practice Address - Country:US
Practice Address - Phone:231-313-1852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-12
Last Update Date:2009-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013859225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist