Provider Demographics
NPI:1194106377
Name:COSCULLUELA, ISAAC SALINAS
Entity type:Individual
Prefix:
First Name:ISAAC
Middle Name:SALINAS
Last Name:COSCULLUELA
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 1:7567 CENTRAL PARKE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-6855
Mailing Address - Country:US
Mailing Address - Phone:513-701-6104
Mailing Address - Fax:
Practice Address - Street 1:9525 KENWOOD RD STE 10A
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-6177
Practice Address - Country:US
Practice Address - Phone:513-745-9877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-14
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
OHPT-020694225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program