MEDICARE: JOHNNY REYNALDO SABOGAL OTR

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	225X00000X	Occupational Therapist	OT11125	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y902L	OTHER	FL	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1528131729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNNY REYNALDO SABOGAL OTR

Provider Business Mailing Address
First Line	:	838 SW 56TH ST
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33914-7223
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1650 MEDICAL LN
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-1116
Country	:	US
Telephone Number	:	239-277-9818
Fax Number	:

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

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	07/09/2007

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