Healthcare Provider Details

I. General information

NPI: 1548857337
Provider Name (Legal Business Name): AMPAI BURBACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2020
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 N PEARL LAKE CSWY UNIT 202
ALTAMONTE SPRINGS FL
32714-2940
US

IV. Provider business mailing address

175 N PEARL LAKE CSWY UNIT 202
ALTAMONTE SPRINGS FL
32714-2940
US

V. Phone/Fax

Practice location:
  • Phone: 407-782-9576
  • Fax:
Mailing address:
  • Phone: 407-782-9576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA30309
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: