Healthcare Provider Details

I. General information

NPI: 1962674564
Provider Name (Legal Business Name): JEROME VANDAL P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2008
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 TURKEY LAKE RD SUITE 203
ORLANDO FL
32819-4200
US

IV. Provider business mailing address

6000 TURKEY LAKE RD SUITE 203
ORLANDO FL
32819-4200
US

V. Phone/Fax

Practice location:
  • Phone: 407-352-3508
  • Fax: 407-352-1219
Mailing address:
  • Phone: 407-352-3508
  • Fax: 407-352-1219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT17672
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: