Healthcare Provider Details

I. General information

NPI: 1235245093
Provider Name (Legal Business Name): EUGENE QUIAMBAO OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9436 AZALEA RIDGE WAY
GOTHA FL
34734-5064
US

IV. Provider business mailing address

9436 AZALEA RIDGE WAY
GOTHA FL
34734-5064
US

V. Phone/Fax

Practice location:
  • Phone: 407-523-6987
  • Fax:
Mailing address:
  • Phone: 407-523-6987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0006931
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: