Provider Demographics
NPI:1811301815
Name:MASHALA, BOITUMELO JOHN EDMUND (PTA)
Entity type:Individual
Prefix:MR
First Name:BOITUMELO
Middle Name:JOHN EDMUND
Last Name:MASHALA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 CHESTNUT CT
Mailing Address - Street 2:APT H
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135-7309
Mailing Address - Country:US
Mailing Address - Phone:574-596-1539
Mailing Address - Fax:
Practice Address - Street 1:1150 CHESTNUT CT
Practice Address - Street 2:APT H
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-7309
Practice Address - Country:US
Practice Address - Phone:574-596-1539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004423A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant