Healthcare Provider Details

I. General information

NPI: 1083640551
Provider Name (Legal Business Name): DONALD JACK RALEY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 US HIGHWAY 441 N
OKEECHOBEE FL
34972-1922
US

IV. Provider business mailing address

1920 US HIGHWAY 441 N
OKEECHOBEE FL
34972-1922
US

V. Phone/Fax

Practice location:
  • Phone: 863-763-8100
  • Fax: 863-763-8669
Mailing address:
  • Phone: 863-763-8100
  • Fax: 863-763-8669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 19035
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: