Healthcare Provider Details

I. General information

NPI: 1508599077
Provider Name (Legal Business Name): CARL WILLIAM P VILLAFUERTE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2022
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5806 PACIFIC BLVD
HUNTINGTON PARK CA
90255-2618
US

IV. Provider business mailing address

1580 SAWGRASS CORPORATE PKWY STE 200
SUNRISE FL
33323-2869
US

V. Phone/Fax

Practice location:
  • Phone: 818-894-2273
  • Fax: 818-357-2505
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT030325
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number309898
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: