Healthcare Provider Details

I. General information

NPI: 1679172332
Provider Name (Legal Business Name): ROGER A. TABATT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2020
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13800 VETERANS WAY
ORLANDO FL
32827-7401
US

IV. Provider business mailing address

13800 VETERANS WAY
ORLANDO FL
32827-7401
US

V. Phone/Fax

Practice location:
  • Phone: 407-631-6031
  • Fax:
Mailing address:
  • Phone: 407-631-6031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number83152
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: