Healthcare Provider Details

I. General information

NPI: 1770008914
Provider Name (Legal Business Name): MR. MARIO DEON BALLANTYNE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3945 ROSE OF SHARON DR
ORLANDO FL
32808-2738
US

IV. Provider business mailing address

3945 ROSE OF SHARON DR
ORLANDO FL
32808-2738
US

V. Phone/Fax

Practice location:
  • Phone: 321-279-1218
  • Fax: 407-704-4464
Mailing address:
  • Phone: 321-279-1218
  • Fax: 407-704-4464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License NumberB453544754290
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License NumberB453544754290
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: