MEDICARE: DR. SHELBY FUENTES PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	9654	SC
2	225100000X	Physical Therapist	1386162	TX
3	2251N0400X	Neurology Physical Therapist	041958-1	NY
4	225100000X	Physical Therapist	37408	FL

General Provider Information

NPI Number	:	1457879371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHELBY FUENTES PT, DPT

Provider Business Mailing Address
First Line	:	11261 SHADY GLEN DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257
Country	:	US
Telephone Number	:	585-451-8733
Fax Number	:

Provider Business Practice Location Address
First Line	:	11705 SAN JOSE BLVD STE 111
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-1653
Country	:	US
Telephone Number	:	904-345-7450
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2017
Last Update Date	:	11/30/2023

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