Provider Demographics
NPI:1194911933
Name:VILLANUEVA, WIRT RAINIER (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MR
First Name:WIRT
Middle Name:RAINIER
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ETTY CT
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NJ
Mailing Address - Zip Code:08759-5918
Mailing Address - Country:US
Mailing Address - Phone:732-323-8628
Mailing Address - Fax:
Practice Address - Street 1:75 OLD TOMS RIVER RD
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-7800
Practice Address - Country:US
Practice Address - Phone:732-451-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA010091002251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics