Healthcare Provider Details

I. General information

NPI: 1578706057
Provider Name (Legal Business Name): MIGUEL TRAIFALGAR DECASTRO JR. PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2009
Last Update Date: 04/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4730 BEE RIDGE RD
SARASOTA FL
34233-1442
US

IV. Provider business mailing address

6722 71ST ST E
BRADENTON FL
34203-7173
US

V. Phone/Fax

Practice location:
  • Phone: 941-377-1286
  • Fax:
Mailing address:
  • Phone: 941-758-1283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT-20585
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: