Healthcare Provider Details

I. General information

NPI: 1487004578
Provider Name (Legal Business Name): CASEY MOKRES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 06/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5535 S WILLIAMSON BLVD SUITE 774
PORT ORANGE FL
32128-8311
US

IV. Provider business mailing address

5535 S WILLIAMSON BLVD SUITE 774
PORT ORANGE FL
32128-8311
US

V. Phone/Fax

Practice location:
  • Phone: 800-330-7711
  • Fax:
Mailing address:
  • Phone: 800-330-7711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number41401
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: