Provider Demographics
NPI:1639481401
Name:ACOSTA, PABLO ENRIQUE (DPT)
Entity type:Individual
Prefix:
First Name:PABLO
Middle Name:ENRIQUE
Last Name:ACOSTA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 LAUREL RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-5112
Mailing Address - Country:US
Mailing Address - Phone:516-330-4882
Mailing Address - Fax:
Practice Address - Street 1:550 E ANN ARBOR AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-6718
Practice Address - Country:US
Practice Address - Phone:214-376-1701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1195597314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility