Healthcare Provider Details

I. General information

NPI: 1164026902
Provider Name (Legal Business Name): ALIA J WANTUCH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4606 CLYDE MORRIS BLVD STE 1D
PORT ORANGE FL
32129-7453
US

IV. Provider business mailing address

1820 CREEKWATER BLVD
PORT ORANGE FL
32128-4088
US

V. Phone/Fax

Practice location:
  • Phone: 386-492-2986
  • Fax:
Mailing address:
  • Phone: 386-871-4431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA30714
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: