Healthcare Provider Details

I. General information

NPI: 1588385538
Provider Name (Legal Business Name): ERNESTO LLANES SOROLLA PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2022
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14921 SW 283RD ST APT 202
HOMESTEAD FL
33033-1583
US

IV. Provider business mailing address

14921 SW 283RD ST APT 202
HOMESTEAD FL
33033-1583
US

V. Phone/Fax

Practice location:
  • Phone: 305-873-4208
  • Fax:
Mailing address:
  • Phone: 305-873-4208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA32292
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: