Healthcare Provider Details

I. General information

NPI: 1700529377
Provider Name (Legal Business Name): MICHAEL BERTULFO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2022
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2512 NE 1ST BLVD STE 400
GAINESVILLE FL
32609-3026
US

IV. Provider business mailing address

2512 NE 1ST BLVD STE 400
GAINESVILLE FL
32609-3026
US

V. Phone/Fax

Practice location:
  • Phone: 813-428-2043
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: