Healthcare Provider Details

I. General information

NPI: 1225312804
Provider Name (Legal Business Name): MR. ROLANDO JET BACALZO GUMBA II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2011
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 SAWGRASS CORPORATE PKWY STE 100
SUNRISE FL
33323-2860
US

IV. Provider business mailing address

1580 SAWGRASS CORPORATE PKWY STE 100
SUNRISE FL
33323-2860
US

V. Phone/Fax

Practice location:
  • Phone: 352-346-8420
  • Fax:
Mailing address:
  • Phone: 352-346-8420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberJ1-0002693
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: