Healthcare Provider Details

I. General information

NPI: 1548667520
Provider Name (Legal Business Name): LEONILO PABLO JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2014
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 PARK AVE
ORANGE PARK FL
32073-4152
US

IV. Provider business mailing address

12357 HOLLOW GLADE CT
JACKSONVILLE FL
32246-4205
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-2437
  • Fax: 904-264-2330
Mailing address:
  • Phone: 904-269-2437
  • Fax: 904-264-2330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT29880
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: