Healthcare Provider Details

I. General information

NPI: 1174281828
Provider Name (Legal Business Name): JEREMY DOUGLAS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2021
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4842 SW ARCHER RD
GAINESVILLE FL
32608-3813
US

IV. Provider business mailing address

8477 S SUNCOAST BLVD
HOMOSASSA FL
34446-5028
US

V. Phone/Fax

Practice location:
  • Phone: 352-378-7172
  • Fax: 352-382-1146
Mailing address:
  • Phone: 800-804-9961
  • Fax: 352-382-1146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA27275
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: