Provider Demographics
NPI:1861102766
Name:BALDEVISO, CEDRIC ALFRED LABASTILLA
Entity type:Individual
Prefix:MR
First Name:CEDRIC ALFRED
Middle Name:LABASTILLA
Last Name:BALDEVISO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 BRIGHTON 6TH ST APT 4A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-6946
Mailing Address - Country:US
Mailing Address - Phone:347-222-7073
Mailing Address - Fax:
Practice Address - Street 1:3130 BRIGHTON 6TH ST APT 4A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6946
Practice Address - Country:US
Practice Address - Phone:347-222-7073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04151701225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist