Healthcare Provider Details

I. General information

NPI: 1285211847
Provider Name (Legal Business Name): JAVONTE FREDERICKS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2021
Last Update Date: 03/28/2021
Certification Date: 03/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 ONE CENTER BLVD APT 208
ALTAMONTE SPRINGS FL
32701-2240
US

IV. Provider business mailing address

535 ONE CENTER BLVD APT 208
ALTAMONTE SPRINGS FL
32701-2240
US

V. Phone/Fax

Practice location:
  • Phone: 321-202-1749
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPTA30943
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: