Healthcare Provider Details

I. General information

NPI: 1508585241
Provider Name (Legal Business Name): PETER JAMES VERGARA CAMPOMANES PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CELEBRATION PL # C200
CELEBRATION FL
34747-4970
US

IV. Provider business mailing address

1138 S PINE RIDGE CIR
SANFORD FL
32773-4806
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-4003
  • Fax:
Mailing address:
  • Phone: 732-859-0150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number25847
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: