Healthcare Provider Details

I. General information

NPI: 1811730708
Provider Name (Legal Business Name): LIAM PRUNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 PARK CENTER DR FL 2302
ORLANDO FL
32835-6235
US

IV. Provider business mailing address

4276 GUMBO LIMBO DR
ORLANDO FL
32822-3118
US

V. Phone/Fax

Practice location:
  • Phone: 321-445-1287
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA19916
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: