Provider Demographics
NPI:1780460279
Name:VELICARIA, KHAIL EDSEL RONQUILLO
Entity type:Individual
Prefix:
First Name:KHAIL EDSEL
Middle Name:RONQUILLO
Last Name:VELICARIA
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 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2838 E ATLANTA RD STE 2
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-2780
Practice Address - Country:US
Practice Address - Phone:678-782-3609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT012282225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist