Healthcare Provider Details

I. General information

NPI: 1790799906
Provider Name (Legal Business Name): MICHAEL C VIA MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9051 TAMIAMI TRL N SUITE 104
NAPLES FL
34108-2596
US

IV. Provider business mailing address

5150 OLD ASHWOOD DR
SARASOTA FL
34233-3491
US

V. Phone/Fax

Practice location:
  • Phone: 239-591-4711
  • Fax: 239-593-1195
Mailing address:
  • Phone: 941-929-9220
  • Fax: 239-593-1195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT12074
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: