Provider Demographics
NPI:1124801535
Name:NATIVIDAD, CARL MICO ROJALES (PT, CLT, CWS)
Entity type:Individual
Prefix:
First Name:CARL MICO
Middle Name:ROJALES
Last Name:NATIVIDAD
Suffix:
Gender:M
Credentials:PT, CLT, CWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8995 SWAYING MEADOWS CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89178-6563
Mailing Address - Country:US
Mailing Address - Phone:725-910-2884
Mailing Address - Fax:
Practice Address - Street 1:640 W BROADWAY
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-2900
Practice Address - Country:US
Practice Address - Phone:516-431-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044627-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist