Healthcare Provider Details

I. General information

NPI: 1184221590
Provider Name (Legal Business Name): ALEJANDRO ANTONIO LAZCANO PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 S UNIVERSITY DR STE 106
DAVIE FL
33328-3809
US

IV. Provider business mailing address

9324 SW 154TH AVE
MIAMI FL
33196-1140
US

V. Phone/Fax

Practice location:
  • Phone: 954-705-5151
  • Fax:
Mailing address:
  • Phone: 786-286-7989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number36152
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: