Healthcare Provider Details

I. General information

NPI: 1801142914
Provider Name (Legal Business Name): JEREMY SOLO CAGOCO LIWASAN P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 07/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7580 OMNI LN APT 201
FORT MYERS FL
33905-5481
US

IV. Provider business mailing address

16089 POPPYSEED CIR UNIT 2008
DELRAY BEACH FL
33484-6314
US

V. Phone/Fax

Practice location:
  • Phone: 716-867-2006
  • Fax:
Mailing address:
  • Phone: 716-867-2006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT25182
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070017602
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number029263
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: