Healthcare Provider Details

I. General information

NPI: 1841611548
Provider Name (Legal Business Name): MICHAEL MARTEENY PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2013
Last Update Date: 12/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 S CLYDE MORRIS BLVD STE. D
PORT ORANGE FL
32129-5294
US

IV. Provider business mailing address

829 OLEANDER AVE
DAYTONA BEACH FL
32117-3433
US

V. Phone/Fax

Practice location:
  • Phone: 386-492-2986
  • Fax: 386-492-2987
Mailing address:
  • Phone: 386-265-2275
  • Fax: 386-492-2987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number24586
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: