Healthcare Provider Details

I. General information

NPI: 1710569249
Provider Name (Legal Business Name): PAUL STOCKWELL RPGST, CRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2021
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 W NEW HAVEN AVE
MELBOURNE FL
32904-3920
US

IV. Provider business mailing address

2090 STRATFORD POINTE DR
WEST MELBOURNE FL
32904-8007
US

V. Phone/Fax

Practice location:
  • Phone: 321-768-6119
  • Fax:
Mailing address:
  • Phone: 646-269-9324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License NumberTT16549
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: