Healthcare Provider Details

I. General information

NPI: 1649649724
Provider Name (Legal Business Name): ALEX WILBURN LPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 09/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 SW SAINT LUCIE WEST BLVD SUITE 202
PORT ST LUCIE FL
34986-1927
US

IV. Provider business mailing address

1680 SW SAINT LUCIE WEST BLVD SUITE 202
PORT ST LUCIE FL
34986-1927
US

V. Phone/Fax

Practice location:
  • Phone: 772-878-3322
  • Fax: 772-878-5030
Mailing address:
  • Phone: 772-878-3322
  • Fax: 772-878-5030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number25880
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: