Healthcare Provider Details

I. General information

NPI: 1164793964
Provider Name (Legal Business Name): STEPHEN HARRY DAGEN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 NW 86THTERRACE
GAINESVILLE FL
32607
US

IV. Provider business mailing address

226 NW 86THTERRACE
GAINESVILLE FL
32607
US

V. Phone/Fax

Practice location:
  • Phone: 352-215-4038
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT4149
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: