Healthcare Provider Details

I. General information

NPI: 1366786287
Provider Name (Legal Business Name): STANLEY CICERON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2113 DAVIE BLVD APT 244
DAVIE FL
33312-3126
US

IV. Provider business mailing address

2113 DAVIE BLVD APT 244
DAVIE FL
33312-3126
US

V. Phone/Fax

Practice location:
  • Phone: 516-864-3608
  • Fax:
Mailing address:
  • Phone: 516-864-3608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number23764
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: