Provider Demographics
NPI:1386976181
Name:VEGA, DAVID CARLOS (PT)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:CARLOS
Last Name:VEGA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 13TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56304-2228
Mailing Address - Country:US
Mailing Address - Phone:320-241-9481
Mailing Address - Fax:
Practice Address - Street 1:1810 MINNESOTA BLVD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56304-2436
Practice Address - Country:US
Practice Address - Phone:320-229-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5466225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist