Provider Demographics
NPI:1861893745
Name:REQUENA, EMMANUEL SR
Entity type:Individual
Prefix:MR
First Name:EMMANUEL
Middle Name:
Last Name:REQUENA
Suffix:SR
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 1:9219 BARBARA LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4702
Mailing Address - Country:US
Mailing Address - Phone:260-579-1748
Mailing Address - Fax:
Practice Address - Street 1:20 JOHN KISSINGER DR
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-1648
Practice Address - Country:US
Practice Address - Phone:260-274-0868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004053A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist