Healthcare Provider Details

I. General information

NPI: 1477083160
Provider Name (Legal Business Name): HOMER BUSI PIQUE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12272 WEST SAMPLE ROAD
CORAL SPRING FL
33065
US

IV. Provider business mailing address

12272 W SAMPLE RD
CORAL SPRINGS FL
33065-4227
US

V. Phone/Fax

Practice location:
  • Phone: 571-215-6850
  • Fax:
Mailing address:
  • Phone: 571-215-6850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2128459
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: