Healthcare Provider Details

I. General information

NPI: 1063097251
Provider Name (Legal Business Name): ROBERT REVELS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2021
Last Update Date: 03/10/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12823 80TH AVE
SEMINOLE FL
33776-3626
US

IV. Provider business mailing address

12823 80TH AVE
SEMINOLE FL
33776-3626
US

V. Phone/Fax

Practice location:
  • Phone: 352-672-1741
  • Fax:
Mailing address:
  • Phone: 352-672-1741
  • Fax: 855-232-8604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number29320
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: