Provider Demographics
NPI:1487931184
Name:CANDA, RAYMOND RENE LUCIO (RPT)
Entity type:Individual
Prefix:
First Name:RAYMOND RENE
Middle Name:LUCIO
Last Name:CANDA
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 UNIVERSITY COMMONS
Mailing Address - Street 2:SUITE 403
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1571
Mailing Address - Country:US
Mailing Address - Phone:574-968-2851
Mailing Address - Fax:
Practice Address - Street 1:211 N EDDY ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-3096
Practice Address - Country:US
Practice Address - Phone:574-334-7410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO021792251P0200X
IN05005612A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics