Individual
MR. MAYNARD VILLAVICENCIO UTAYDE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
1409 E DAY RD, MISHAWAKA, IN 46545-3671
(574) 257-9880
Mailing address
51470 NORWICH DR, GRANGER, IN 46530-8426
(574) 257-9880
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
05005198A
IN
Other
Enumeration date
01/03/2007
Last updated
07/17/2016
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