Healthcare Provider Details

I. General information

NPI: 1932342342
Provider Name (Legal Business Name): MARICEL RIVERA RONQUILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2009
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 ORANGE DR
ALTAMONTE SPRINGS FL
32701-5377
US

IV. Provider business mailing address

260 1ST AVE S STE 200
SAINT PETERSBURG FL
33701-4364
US

V. Phone/Fax

Practice location:
  • Phone: 407-576-5712
  • Fax:
Mailing address:
  • Phone: 727-308-9848
  • Fax: 727-502-6027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT009221
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT29085
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT29087
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: