Healthcare Provider Details

I. General information

NPI: 1093201097
Provider Name (Legal Business Name): KEVIN DAVID DIANA PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2018
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2884 WELLNESS AVE
ORANGE CITY FL
32763-8426
US

IV. Provider business mailing address

120 WILLOWBAY RIDGE ST
SANFORD FL
32771-7990
US

V. Phone/Fax

Practice location:
  • Phone: 386-774-4404
  • Fax: 386-774-4496
Mailing address:
  • Phone: 321-662-1174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number17272
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: