Healthcare Provider Details

I. General information

NPI: 1821678582
Provider Name (Legal Business Name): PAUL MARVIN THEILE CTRS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2021
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 SW ARCHER RD
GAINESVILLE FL
32608-1135
US

IV. Provider business mailing address

122 SE 70TH CIR
OCALA FL
34472-7962
US

V. Phone/Fax

Practice location:
  • Phone: 352-376-1611
  • Fax:
Mailing address:
  • Phone: 352-615-0936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number80710
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: