Provider Demographics
NPI:1881062115
Name:MIX, ZACHARY
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:MIX
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 1:111 CLARA BARTON ST
Mailing Address - Street 2:
Mailing Address - City:DANSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14437-9503
Mailing Address - Country:US
Mailing Address - Phone:585-335-4217
Mailing Address - Fax:585-335-5044
Practice Address - Street 1:111 CLARA BARTON ST
Practice Address - Street 2:
Practice Address - City:DANSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14437-9503
Practice Address - Country:US
Practice Address - Phone:585-335-4217
Practice Address - Fax:585-335-5044
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY039415OtherLICENSE