Healthcare Provider Details

I. General information

NPI: 1699115576
Provider Name (Legal Business Name): BRIDGET LLAVE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4511 SW 48TH AVE
OCALA FL
34474-9626
US

IV. Provider business mailing address

5510 SW 41ST BLVD SUITE 202
GAINESVILLE FL
32608-4977
US

V. Phone/Fax

Practice location:
  • Phone: 866-236-1808
  • Fax: 866-236-1808
Mailing address:
  • Phone: 855-297-8326
  • Fax: 888-503-7832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA18744
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: