Healthcare Provider Details

I. General information

NPI: 1477419430
Provider Name (Legal Business Name): JUAN PABLO TOVAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2026
Last Update Date: 01/02/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 N WICKHAM RD # 300
MELBOURNE FL
32935-8648
US

IV. Provider business mailing address

812 POINCIANA ST
ROCKLEDGE FL
32955-4114
US

V. Phone/Fax

Practice location:
  • Phone: 321-622-6884
  • Fax:
Mailing address:
  • Phone: 689-271-3634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: