Healthcare Provider Details

I. General information

NPI: 1770688681
Provider Name (Legal Business Name): JOHN ANTHONY TAMBASCO SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3157 N UNIVERSITY DR SUITE 103
PEMBROKE PINES FL
33024-2258
US

IV. Provider business mailing address

3157 N UNIVERSITY DR SUITE 103
PEMBROKE PINES FL
33024-2258
US

V. Phone/Fax

Practice location:
  • Phone: 954-442-9422
  • Fax: 954-442-9150
Mailing address:
  • Phone: 954-442-9422
  • Fax: 954-442-9150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA 4906
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: