Healthcare Provider Details

I. General information

NPI: 1700174661
Provider Name (Legal Business Name): ANGELA BUENO PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2011
Last Update Date: 05/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 W EAU GALLIE BLVD SUITE 180
MELBOURNE FL
32934-7213
US

IV. Provider business mailing address

175 HIGHWAY A1A #111
SATELLITE BEACH FL
32937-2076
US

V. Phone/Fax

Practice location:
  • Phone: 321-255-6627
  • Fax: 321-253-9777
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT26571
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: