Healthcare Provider Details

I. General information

NPI: 1871582262
Provider Name (Legal Business Name): EUGENE SELSO MONTANO PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1381 S PATRICK DR
PATRICK AFB FL
32925-3606
US

IV. Provider business mailing address

655 7TH ST BLDG 700/700-A 78 MDG/SGOY
ROBINS AFB GA
31098-2227
US

V. Phone/Fax

Practice location:
  • Phone: 321-494-0930
  • Fax: 321-494-8294
Mailing address:
  • Phone: 478-327-7798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number30737
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: