Healthcare Provider Details

I. General information

NPI: 1790894418
Provider Name (Legal Business Name): MATTHEW C SERLO MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 PONTE VEDRA PARK DR SUITE 300
PONTE VEDRA FL
32082-6619
US

IV. Provider business mailing address

PO BOX 441146
KENNESAW GA
30160-9522
US

V. Phone/Fax

Practice location:
  • Phone: 678-459-3758
  • Fax:
Mailing address:
  • Phone: 678-403-3632
  • Fax: 678-567-6737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT19837
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: