Healthcare Provider Details

I. General information

NPI: 1265737191
Provider Name (Legal Business Name): IRVING HAROLD ENSOR PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2011
Last Update Date: 01/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8477 S SUNCOAST BLVD
HOMOSASSA FL
34446-5028
US

IV. Provider business mailing address

14235 EDWINOLA WAY ROOM 831
DADE CITY FL
33523-3763
US

V. Phone/Fax

Practice location:
  • Phone: 352-382-1141
  • Fax: 352-382-1146
Mailing address:
  • Phone: 352-567-5910
  • Fax: 352-567-6860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 22458
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: