Healthcare Provider Details

I. General information

NPI: 1265618987
Provider Name (Legal Business Name): ROBERT LANE FERREIRA DPT, OCS, MTC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2008
Last Update Date: 05/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 SOUTHPARK BLVD SUITE 100
ST AUGUSTINE FL
32086-4120
US

IV. Provider business mailing address

190 SOUTHPARK BLVD SUITE 100
ST AUGUSTINE FL
32086-4120
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-1478
  • Fax: 904-824-8071
Mailing address:
  • Phone: 904-824-1478
  • Fax: 904-824-8071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number23808
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: