Healthcare Provider Details

I. General information

NPI: 1417102724
Provider Name (Legal Business Name): JENEVIEVE SERILO OQUENDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 09/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7201 GREENBORO DR
WEST MELBOURNE FL
32904-1698
US

IV. Provider business mailing address

3952 JOSLIN WAY
WEST MELBOURNE FL
32904-8489
US

V. Phone/Fax

Practice location:
  • Phone: 321-727-0990
  • Fax:
Mailing address:
  • Phone: 858-429-8638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: