Individual
JAY SANVICTORES ICASIANO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1955 VERNON ST, WABASH, IN 46992-4026
(260) 563-8438
Mailing address
866 SIGNATURE ST APT B, BOURBONNAIS, IL 60914-9216
(217) 381-0262
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
06006321
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
06006321
INDIANA LICENSING DEPARTMENT
IN
Enumeration date
07/21/2021
Last updated
07/21/2021
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