Healthcare Provider Details

I. General information

NPI: 1174049977
Provider Name (Legal Business Name): RICARDO VAZ LPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E 3RD AVE UNIT 6
NEW SMYRNA BEACH FL
32169-3104
US

IV. Provider business mailing address

4505 DORIS DR
NEW SMYRNA BEACH FL
32169-4103
US

V. Phone/Fax

Practice location:
  • Phone: 386-597-3992
  • Fax:
Mailing address:
  • Phone: 386-597-3992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number27805
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: